MEDICATION
The member tells you they can't afford to fill their prescription?
Medication is covered: offer to locate a less expensive alternative they can discuss with their doctor. Other options include getting a short fill, asking their doctor for samples, researching coupons and manufacturer discounts, applying for Extra Help, or calling 211.
• Medication is NOT covered: offer to locate a covered alternative drug they can discuss with their doctor, initiate a drug list exception via PromptPA, or if exception request was denied, file an appeal.
Can LA Medicaid assist provider regarding pharmacy calls?
Yes, LA Medicaid will assist prescribers calling in to check for plan coverage as well you may have the pharmacist calling in to verify why a claim denied.
The member calls upset about their medication being denied at the pharmacy?
Respond with a diffusing statement to both acknowledge and emphathize with the caller:
• “I understand why you are concerned, let me look into why that claim was denied”
•"It's unfortunate that happened at the pharmacy, let's see what options are available for you"
The member's drug requires prior authorization?
Offer to find a less restrictive alternative drug they can discuss with their doctor, or offer to initiate an HCPR clinical review via PromptPA.
The member has a Medicaid plan that doesn't include Rx Coverage?
Find out if they have a DSNP or another plan with a different carrier. If they do, connect them to the Duals Designated team. If they don't have Rx coverage with Humana, determine if they have coverage through another insurance carrier.
What is a defined as a controlled drug?
Limited based on accepted medical use, safety, and abuse control.
The pharmacy doesn't carry the specialty drug the member needs?
look for another specialty pharmacy located in Pharmacy Finder.
The member's can't get their prescription filled because the claim is denying for hard error code 090-Submit Claim to Primary Payer?
Determine if the other insurance we have on file in CRM, RxNova, and CAS is correct. If not, complete the Medicare and Medicaid Other Insurance Form in CRM and notify the MET if access to care related
The prior authorization is denied?
Offer to locate covered drug alternatives they can discuss with their doctor, or if not satisfied, they can file an appeal.
The member is looking for assistance with ordering from the OTC catalog?
Advise them that the catalog and form can be found online at Humana.com or through CenterWell pharmacy.
The member said they lost or spilled their medication and can't use it?
Advise them that we can submit a request to see if they would be approved to get the medication with a HCPR escalation form.
The pharmacy can't run the claim through at the pharmacy?
Refer to the Pharmacy Claim Submission Issues Medicaid and MMP guideline. Verify the member's eligibliiy and confirm the Rx GRP, BIN, and PCN numbers being used.
A claim rejects for hard error code 047 - Previous Therapy Excludes This Drug and there's a soft reject message visible?
Conduct a claim test in RxNova using the applicable PPS codes in the DUR/Clinical link to see if the claim can be successfully overridden. If so, provide the codes for the pharmacy to use.
The status of the prior authorization shows EOC aborted?
Advise the member HCPR did not receive the requested information from the doctor and offer to start a new request.
if the medication is being administered in a provider’s office, what other benefit should you quote?
Medical office visit
The member is calling for benefits on diabetic supplies and equipment?
Refer to the Diabetic Coverage Overview Medicaid and MMP guideline. Instructions will direct you to Debut for the correct cost-share of CGM devices and supplies or glucose testing supplies and equipment. Refer to RxConnect Pro for costs of test strips, lancets, and insulin
The member paid out of pocket for the medication at the pharmacy and wants to get reimbursed?
Inform them they have 7-14 days to return to the pharmacy and request to have the claim reprocesed for reimbursement.
What if the member is out of town running short of medication and unable to locate a participating pharmacy?
Attempt to locate a pharmacy for them. If an emergency access to care need exists, consult transfer them to the MET.
A member's claim continues to deny with error code 080 - Refilled Too Soon but is related to a county-wide tornado or hurricane disaster event?
Conduct a claim test using PAC 911911 to verify the charges will process correctly. If so, advise the pharmacy to rerun the claim accordingly.
Where can I find the information that will display a list of medications that need a prior authorization (PA) when administered at the?
Preauthorization and Notification Lists for Healthcare Providers - Humana under Pharmacy Prior Authorization Calls Medicaid mentor doc.
Is the drug on the Preauthorization and Notification List?
Important: The member doesn't have to go through Humana Clinical Pharmacy Review for the drug authorization when MIT enters the medical authorization.
Attention: Don't transfer the caller to MIT.
The member was calling to get benefits on the flu vaccine?
Refer to the Vaccine VOB Member Calls Medicaid guideline which will indicate the vaccine is covered under the member's medical plan.
Pharmacy wasn't able to run the claim due to a 066 error?
This would be the lock-in error 066 code occurs when either the member or the drug isn't eligible to fill prescriptions at this pharmacy.
If trying to choose another pharmacy, they would need to speak with Medicaid: Consult transfer them to Overutilization Review and Monitoring at 833-410-2496 to request a clinical review.
Member is experiencing a 450 error and is not able to get their medications at the pharmacy?
Missing or invalid patient address-
A pharmacy calls asking if the member is eligible for a vacation override?
Verify the situation warrants an override. If so, perform a claim test using SCC 03 to confirm the member isn't exceeding the limit of one override every rolling 12 months.
I was charged a different amount at the pharmacy for my medication. Did my copay change?