Drug utilization review

Humana drug utilization reviews and resources

In the interest of member safety and health, Humana periodically reviews members’ drug utilization as indicated by prescription claims data. These reviews are guided by health care standards published by:

Humana informs health care providers of these reviews through mailings, faxes, e-prescribing messages and Availity Care Profile alerts. Mail and fax initiatives may include a response form inviting health care providers to send comments and a list of actions taken to Humana. Below are some of the main focuses of our drug utilization reviews, along with related resources for health care providers.

Antipsychotic drug use in persons with dementia: No antipsychotic medication is approved by the U.S. Food and Drug Administration (FDA) for the treatment of dementia-related psychosis. Humana mails letters to prescribers who may be using these drugs to treat patients with dementia and alerts prescribers to the safety risks of such usage.

Coronary artery disease and statin use

Humana has implemented a quality program in accordance with the guidelines of the American College of Cardiology/American Heart Association and the National Cholesterol Education Program (NCEP). Statins are the only cholesterol-lowering drugs proven, through randomized trial evidence, to prevent atherosclerotic cardiovascular disease (ASCVD).

Chronic, high-dose acetaminophen (APAP) overutilization: CMS requires us to alert prescribers to patterns of chronic, high-dose acetaminophen use when the daily dose exceeds 4 grams for more than 30 days. (Reports may be sent to all prescribers who have written prescriptions for a patient in order to verify if the dosages and utilization are appropriate, medically necessary and safe


For our members with diabetes, we focus on the following areas of drug utilization: dosing of diabetes medications to reduce adverse drug events and treatment for members with diabetes who are at risk of a heart attack or stroke and/or have elevated cholesterol levels requiring treatment with lipid-lowering medications. Learn more.

Drug-to-drug interactions: Prescribers are notified when a patient has received or has been prescribed two medications that are considered potentially problematic when taken in combination, as identified in standard drug compendia. Depending on the severity of the interactions, the prescriber may receive notifications directly from the pharmacy due to a point-of-service edit, which includes the names of the prescribers and the pharmacies where the prescriptions were filled. Point-of-service edits require authorization be given before the dispensing of medication occurs. Learn more (link opens in new window).

Drug-disease interactions: We alert prescribers by fax when a patient has received a medication that appears to be contraindicated due to evidence of a certain underlying disease, condition or health concern.

High-risk medications

Our high-risk medication initiatives focus on members 65 years of age and older who are receiving prescription medications that are contraindicated or that should be avoided for this age group. Learn more.

Medication adherence

Humana considers a member adherent to his or her medication therapy if the member has a proportion of days covered (PDC) of 80 percent or more. The PDC is calculated by the days of medication supplied divided by total days in a specified time interval. Learn more.

Namenda use in select Humana members: CMS asks Humana to contact health care providers who are prescribing Namenda for Medicare members age 26 and under and to determine the drug’s medical indication for these members. CMS is concerned that prescribers may be using the medication to treat these members for autism, which is an off-label use of the drug. Prescribers may receive a letter and patient report with a fax response form. Humana representatives may call prescribers who do not return the response form.

Opioid overutilization: CMS requires us to alert prescribers to patterns of potentially inappropriate opioid use by their Humana-covered patients. Prescribers may be sent reports requesting they verify dosage(s) and utilization are appropriate, medically necessary and safe. The reports also assist prescribers in coordination of pain management.

Polypharmacy: Humana notifies prescribers when their patients have filled concurrent prescriptions for two or more medications in the same psychotropic class, prescribed by different physicians. Because multiple-medication treatment requires close monitoring for adverse interactions or side effects, it is best accomplished by a single prescribing provider or close collaboration between all prescribers.