Easy
Humana does not cover replacement of lost, stolen, or damaged medications. However, you (the advocate) can offer members some helpful suggestions. Which one of the following is NOT an appropriate suggestion in this case?
- Advise the member to file an appeal with the insurance company for a one-time exception Call
- “211”, a nationwide Help Referral Service for local resources available
- Contact their doctor or manufacturer to see if they have/offer free samples.
- Check if the pharmacy can “loan” a small amount from the next fill.
- Seek reimbursement through their home/renter’s insurance policy.
Advise the member to file an appeal with the insurance company for a one-time exception
A PDP member is traveling across the U.S. to visit family and friends. Can they get their prescriptions filled in any state?
- Yes, they can use any Humana pharmacy or get a vacation supply before they leave if they have not exhausted their limit.
- Yes, but they’ll need to use Humana Pharmacy mail Order for a 90-day supply of the prescription.
- No, if traveling, they will be outside their plan’s service area
Yes, they can use any Humana pharmacy or get a vacation supply before they leave if they have not exhausted their limit.
What is the only exception that would result in Humana covering a lost or damaged medication?
- A disaster exception.
- An isolated personal crisis exception.
- An exception granted by the pharmacy due to prior authorization delay.
-A one-time override request submitted by the member’s doctor
A disaster exception
Where in RxNova Call Connect is a member’s Low Income Subsidy (LIS) status located?
- Benefits & Eligibility Deductible & Accumulators panel.
- Benefits & Eligibility Dual Coverage panel.
- Benefits & Eligibility Part D panel.
Benefits & Eligibility Part D panel.
When researching prescription drug (Part D) claims, where will you confirm if the covered amount applied towards the member’s deductible?
- RxNova Call Connect Reimbursements Paid panel
- RxNova Call Connect Claim Detail Benefits panel
- RxNova Call Connect Benefits & Eligibility Detail panel
RxNova Call Connect Claim Detail Benefits panel
When verifying prescription drug (part D) benefits in RxConnect, how can you tell if a medication is not covered?
- “Not Covered” appears in the Coverage column.
- There are no drug alternatives available.
-The best deal indicator is not visible
“Not Covered” appears in the Coverage column.
When viewing drug pricing results in RxConnect, what indicator represents the best deal for our members?
- Amount corresponding to the green dollar sign.
- Lowest cost in the Total cost column.
- Lowest cost in the Member pays column.
Amount corresponding to the green dollar sign.
When verifying prescription drug (part D) benefits in RxConnect, how will you know if a medication requires prior authorization approval from HCPR? Answer
- When "Prior Authorization”, “B vs D Determination”, or “Step Therapy” appear under the Coverage column.
- When “Quantity Limits” appears in the Coverage column.
- When the medication is Tier 4 or higher
When "Prior Authorization”, “B vs D Determination”, or “Step Therapy” appear under the Coverage column.
When verifying prescription drug (Part D) benefits, where will you confirm if the member has reached or is nearing their initial stage?
Answer
- RXNova Call Connect
- Pharmacy Finder
- CRM
RXNova Call Connect
A member expresses concern over the high copay cost of their prescription that their PCP states is the only effective medication for them. What is the best course of action?
Answer
- Advise the member they can request a tier exception and warm transfer them to HCPR.
- Show empathy and advise them that the estimate is accurate based on their current plan.
- Provide cost-saving alternatives they can discuss with their doctor
Advise the member they can request a tier exception and warm transfer them to HCPR.
When confirming the amount (if any) a member owes on a drug claim, which dollar amount in RxNova Call Connect represents the member’s responsibility?
- Sub Ingr Cost amount
- Patient Paid amount
- Plan Paid amount
Patient Paid amount
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
- Claim
- Reimbursement
Benefits/Eligibility
Which RxNova Call Connect option provides the status of check issued to members who submit a paper claim for Direct Member Reimbursement (DMR)?
- Reimbursement
- Formulary
- Pharmacy
Reimbursement
How can you tell when a drug claim requiring correction was adjusted and reprocessed in RxNova Desktop?
- The claim source will always show “DMR Long”
- A date is visible in the Adjustment date field.
- The plan paid amount will show a dollar amount.
The claim source will always show “DMR Long”
If the indicator under the RxNova Call Connect Dual Coverage panel S shows “ ”, what does this mean?
- The member has other insurance (OI) – Humana is secondary.
- The member does not have other insurance coverage besides Humana.
- The member has other insurance (OI) – Humana is primary.
The member has other insurance (OI) – Humana is secondary.
Mail Order demographic information edited under the Demographics section is limited to ____________.
Answer
- Contact numbers and email addresses.
- Primary phone numbers and email addresses.
- Email addresses only.
- Alternate and Mobile phone numbers only.
Contact numbers and email addresses.
When researching a denied drug claim in RxNova Call Connect, you find error code “082 ” listed under the Errors & Messages panel. What does this mean?
- The medication is a CMS excluded drug.
- The member is attempting to get an early refill.
- Pre-authorization is required through HCPR.
Pre-authorization is required through HCPR.
If, while researching a different denied drug claim, you notice the error code “ ” is listed in the Errors & Messages panel, what does this mean?
Answer
- The medication is for a drug covered under Part B only.
- This is a duplicate charge for a claim previously processed.
- The medication is covered, this is an informational error only.
The medication is for a drug covered under Part B only.
What is the difference between regular and expedited mail?
Answer
- Expedited mail only shortens the shipping time after orders have left the mail order facility.
- Expedited mail shortens the time it takes to process orders.
- All regular mail orders are received the next day.
- There is no difference between the two.
Expedited mail only shortens the shipping time after orders have left the mail order facility.
What order information must be verified with the caller before releasing the call?
Answer
- Shipping address, cost share, and amount of current supply remaining.
- Member cost share.
- Shipping address and member cost share.
- Amount of current supply remaining
Shipping address, cost share, and amount of current supply remaining
What information do you relay to the caller regarding their ordered medication?
Answer
- Name, Dosage, Quantity, Day Supply, Next Fill Date and Remaining Refills
- Type of Rx, Quantity, Next Fill Date, and Day Supply
- Name, Dosage, Quantity, and Day Supply
- Type of Rx, Name, Dosage, and Next Fill Date
Name, Dosage, Quantity, Day Supply, Next Fill Date and Remaining Refills
If the member does not have enough supply on hand to last until delivery, follow the Missing Rx process to obtain a refill locally if a prescription is not already on file, and ______.
-Perform a mail order override.
-Put a rush on the pending order.
-Transfer the caller to Clinical Services.
-Ask the member to remain patient.
Perform a mail order override.
Where in CRM is a member’s Low Income Subsidy (LIS) status located?
- Member page — Eligibility Information section
-Person Account page – Communication panel
- Plan Member page – Authorization/Referral Summary link
- Person Account page – Policies section
Plan Member page — Eligibility Information section
The status of a prior authorization for a prescription drug can be found where in CRM?
- Auth/Referral Summary tab under the Pharmacy Authorization tab.
- Contact Handling Alerts section Policy.
- Member page under the Details tab.
Auth/Referral Summary tab under the Pharmacy Authorization tab.
A member says: "My prescription was $0 last time I refilled it in November, and now in February of this year it’s $325. What happened?!"
- Express empathy and review their benefit phase and claim details.
- Tell the member prices change.
- Transfer to the pharmacy.
- Tell them to call their doctor.
Express empathy and review their benefit phase and claim details