Five Customer Facing Segments
The #1 pharmacy Humana members use
Traditional (mail) Pharmacy
Fixed amount paid at office visits, ER visits, prescriptions
Copayment
DAW
Dispense As Written
Preferred list of drug products that typically limits the number of drugs available within a therapeutic class.
Formulary
What year did Medicare begin?
1965
“Plan side of the business” develops formularies and covered drugs lists
Pharmacy Benefit Management
National health program for eligible individuals and families with low incomes and resources
Medicaid
MOOP
Maximum Out of Pocket
Identifies how much of the active ingredient is present in each dosage.
Strength
Identifies how much of the active ingredient is present in each dosage.
EMPATHY
Nation’s largest full-service pharmacy benefits manager specifically for hospice and palliative care
Enclara Hospice Pharmacy
Determination made by health plan that service is approved
Authorization
GCN
Generic Code Number
Store front locations where members can fill prescriptions they need to take for short term (nonmaintenance).
Retail
Which President signed the bill that eventually became the Medicare and Medicaid federally funded programs?
Lyndon B. Johnson
• Includes: Humana Pharmacy Call Center, Humana Specialty Call Center, and RxEducation
Service Experience & Operations
Federal law restricts access to an individual’s private medical information
Health Insurance Portability and Accountability Act (HIPPA)
DOS
Date of Service
Allows Humana members with prescription coverage to order and receive their maintenance medications through the mail using Humana Pharmacy. Refills can be ordered by mail, phone, or online. Allows members to receive up to a three-month supply on certain medications.
Mail Order
Name one thing we use RXNOVA for?
Test claims/Copays
Full-service specialty pharmacy dispensing medications to treat chronic or complex conditions
The Specialty Pharmacy
Federal government administered health plan
Medicare
PDP
Prescription Drug Plan
Part B coverage; can cover certain medications, as well as diabetic and other medical supply purchased at retail pharmacies
Medicare Advantage
Who is your new bestfriend?
MENTOR