Prior Auths
What team here at Humana handles the prior authorizations for pharmacy?
HCPR
True or False: We can preform an override if a member loses or has their medication stolen?
FALSE!
What claim status code indicated a claim denial in RX Nova?
DNY or DNI
What system do we use to verify RX benefits?
RX Connect Pro
What program can be offered to members that can allow them to make a monthly payment for their medications instead of paying full cost up front at the pharmacy?
Medicare Prescription Payment Plan.
When quoting RX benefits in RX Connect Pro, how do we know if a medication is going to require a prior authorization?
“Prior Authorization”, “B vs D Determination”, or “Step Therapy” appears under the Coverage column
When can we as advocates preform overrides?
Mail Order Delay, Disaster Exception, COB issues, and Vacation Overrides.
What tab on the claim details page will tell us the medication tier?
Benefits tab
What are the stages of the Medicare Part D Prescription Drug Plans?
Deductible, Initial Coverage, and Catastrophic.
Where in RX Connect can we find centerwell mail order information?
Order Tracking
What are the turnaround times for RX prior authorizations?
72 Hours for standard, 24 Hours for expeditated.
What code does the pharmacy use to do a vacation override?
Submission clarification code 003
What information does the pharmacy need from a Member's ID Card to process a claim under their insurance?
RX PCN, BIN, and group.
What are the Plan Product Types Codes that indicate the member has Part D Coverage in CRM?
MAPD and PDP
According to the Extra Help/LIS Comparison guideline, if a member’s LIS status shows 1001, what subsidy level is this?
Subsidy Level 3
What determines if a member is eligible for a Tier Exception?
Tier Level, if its covered or non-covered, if there is any lower cost or tier level drug alternatives.
If member was having an issue with another insurance showing on file and it causing their medication to deny, what override would we preform and what hard error would we see that indicates this issue?
COB override: code 090- submit to primary payor
If, while researching a different denied drug claim, you notice error code “221” is listed in the Errors & Messages panel, what does this mean? (Use your mentor)
The medication is for a drug covered under Part B only.
The Member ID link from this RxNova Call Connect button is launched if needing to review a member’s pharmacy accumulations from the previous plan year
Benefits/Eligibility
The exact maximum number of continuous days a member can go without "creditable" prescription drug coverage before an LEP begins accumulating
63 days
How can we identify a compound medication and what steps do we take if a Pre-auth is required?
If the results don't bear results, the medication can be a compound drug. When a prior authorization is required for an ingredient, refer members to Humana Clinical Pharmacy Review.
How can you tell when a drug claim requiring correction was adjusted and reprocessed in RxNova Desktop?
A date is visible in the Adjustment date field.
How can we tell what part of the members plan a prescription claim processed under (i.e. Part B or Part D)
Post Pay 4 box on claims detail page.
What happens to members who do not enroll in a drug plan when they first become eligible or choose to cancel their drug coverage?
They can be issued the Late Enrollment Penalty
What insulin products is covered under Part D?
• Insulin syringes (including needle-free syringes)
• Insulin pens
• Insulin injections
• Gauze pads
• Alcohol swabs
• Disposable insulin pumps and the insulin used in the disposable pump