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 providers of these reviews through mailings, faxes, eprescribing 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.
Chronic, high-dose acetaminophen (APAP) overutilization: The Centers for Medicare & Medicaid Services (CMS) requires us to alert prescribers to patterns of chronic, high-dose acetaminophen use when the daily dose exceeds 4 grams per day for more than 30 days. Reports may be sent to all prescribers who have written prescriptions for a patient to verify the dosages or utilization is appropriate, medically necessary and safe.
For our members with diabetes, we focus on two main areas of drug utilization: dosing of diabetes medications and optimal treatment for members who also have hypertension.
Drug-to-drug interactions: We send faxes to prescribers to notify them that a patient has received two medications that are considered potentially problematic when taken in combination, as identified in standard drug compendia. These faxes include the names of the prescribers and the pharmacies where the prescriptions were filled.
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.
Our high-risk medication initiatives focus on members 65 years of age and older who are receiving prescription medications contraindicated for this age group.
Humana considers a member adherent to his or her medication 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.
Namenda use in select Humana members: The Centers for Medicare & Medicaid Services (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.
The Centers for Medicare & Medicaid Services (CMS) requires us to alert prescribers to patterns of potentially inappropriate opioid use by their Humana-covered patients. Our special investigations unit may send reports to all prescribers who have written prescriptions for a patient to verify the dosages or utilization is appropriate, medically necessary and safe.