Utilization management for provider-administered drugs

Starting with dates of service on or after Jan. 1, 2022, certain specialty medications administered in the outpatient hospital setting must be dispensed and associated claims must be submitted by a Humana network specialty pharmacy.

For more information about the affected specialty medications, please refer to Humana’s Prior Authorization List.

Sourcing, billing and administration of specialty medication

The outpatient hospital is no longer financially responsible for the procurement of certain specialty drugs. Specialty pharmacies send the medication directly to the outpatient hospital and are reimbursed directly by Humana.

The provider will continue to obtain preauthorization, source and administer the medication. Sourcing of the medication and billing of the pharmacy claim must occur prior to administration. The process to reimburse the provider for the administration service will not change. Alternatively, if a member is clinically eligible to receive therapy in the home or through an Ambulatory Infusion Suite, that may be an option through our Site of Care program.

Humana plans affected

The Humana plans affected by this process are Level Funded Premium, Fully Insured (except where exclusions apply) and traditional Administrative Services Only (ASO), except where exclusions apply.

The Humana plans that are excluded from this process are:

• Commercial groups with policies issued in Tennessee and Louisiana
• Commercial groups that opt out of medical utilization management for pharmacy products and ASO groups that carve out pharmacy benefits to another entity (medical-only customers)
• Medicaid
• Medicare