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Drug Benefits
Coverage Determinations
Action for RxNova
Rx Refresh
Miscellaneous
100

What are the 2 tools we use for RX calls?

RxConnect & Rx Nova

100

What is the C/I for prior authorization calls?

Rx/Prior Authorization

100

True or False:

Code 020 produce an error and medication cant be dispensed and the time of refill.

False 020 its just an informational code.

100

What is the type of request that ask Humana to cover a non-covered drug?

Drug list exception

100

How does the extra help icon look in CRM?

Green pill bottle icon

200

Name the 4 therapeutic drug class classifications.

Stains, High blood pressures (hypertension), opioids & antidepressants. 

200

What humana deparment helps with pri authorization process?

Humana Clinical Pharmacy Review team (HCPR)

200

What is the Call handling process for error code 542?

  • • Tell the caller this drug hasn't been proven to be safe and effective in the treatment of the diagnosis provided on their pharmacy claim.
  • .
  • - If the caller requests coverage for the drug, a prior authorization is required from the prescribing provider.
  • .
  • - If the caller asks to speak with someone to start the prior authorization request:
  • .
  • Medicare - Consult transfer the call to Humana Clinical Pharmacy Review.
  • Medicaid - Refer to Request a Prior Authorization Form Using PromptPA.
  • .
  • Note: Error code 542 is not eligible for a transition fill and does not pay without an authorization.

Diabetic Medication for Weight Loss Control Guidance

Note: Rx Connect Pro has a Diagnosis required indicator to help recognize these medications.

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  • Examples:
  • .
  • • Adlyxin (lixisenatide)
  • • Bydureon (exenatide)
  • • Byetta (exenatide)
  • • Mounjaro (tirzepatide)
  • • Ozempic (semaglutide)
  • • Rybelsus (semaglutide)
  • • Trulicity (dulaglutide)
  • • Victoza (liraglutide)
  • .
  • a. Tell the caller the following:
  • .
  • • The drug hasn't been proven to be safe and effective in the treatment of the diagnosis provided on their pharmacy claim.
  • .
  • • These medications are only approvable for patients with documented Type 2 Diabetes diagnosis.
  • • The claim can be resubmitted with the appropriate ICD-10/diagnosis code.
  • .
  • b. Offer to call the pharmacy to request resubmission of the claim with an appropriate ICD-10/diagnosis code.
  • .
  • Note: Error code 542 isn't eligible for transition fill.
  • .
  • c. Goto Diabetic Care Overview Medicare for additional information about these drugs.
200

Explain the tier exception.

type of request ask Humana to cover higher tier medication at a lower tier resulting in a reduced cost for members.
200

Who is Humana's preferred mail order supplier for specialty medication?

CenterWell Specialist Pharmacy

300

True or False:

If Rxconnect does not show an alternative medication, we should advise the member to contact their doctor for guidance.

True

300

How can a prescriber or member initiate the prior authorization process?

Online, by fax or over the phone

300

What is the Call handling process for error code 496?

  • • If the caller is the member,
  • .
  • - Tell the caller that this claim is the first time they're receiving opioid medications and a member who has not used opioids for more than seven consecutive days during the previous 30 days is limited to no more than a 7-day fil. Some LOB only allow a 3-day fill.
  • .
  • Refer to Opioid/Pain Medication Frequently Asked Questions.
  • .
  • - If the member is new to Humana, tell them that we're unable to see their previous claim history with another insurance carrier. Their pharmacy can review prior claims history and apply a Professional Pharmacy Service (PPS) code to override this denial. Offer to make an outbound call to the pharmacy to remove the member from the middle. Use the guidance provided for pharmacy as needed.
  • - If the pharmacist does not enter the PPS code, the patient or provider can request a prior authorization. Refer to Request a Prior Authorization Form Using PromptPA.
  • .
  • • If the caller is the prescriber, tell them that if they believe that the member must receive the rejected quantity of opioid medicated, they must contact Humana Clinical Pharmacy Review to request an exception.
  • .
  • • If the caller is the pharmacy,
  • .
  • a. Tell them that the opioid claim is more than the initial fill limitation of a seven-day supply. Some LOB only allow a 3-day fill.
  • .
  • Refer to Opioid/Pain Medication Frequently Asked Questions.
  • .
  • b. Tell them that Humana has added functionality to allow pharmacists to consult the patient's medication history or consult the state's Prescription Drug Monitoring System for previous opioid use within the following time frames:
  • .
  • Medicare and MMP: 108 days
  • Medicaid: 60 days
  • .
  • - If the pharmacist determines the patient isn't opioid-naïve, the claim could be overridden through entry of appropriate Drug Utilization Review/pharmacy professional service codes.
  • - If the pharmacist is unable to resolve or submit the appropriate code, the error code requires clinical review for appropriate days supply.
  • - The pharmacist should advise the member, the prescriber can request coverage determination through HCPR.
300

How can you describe vaccines?

antibodies that help guard the body's defenses against disease.

300

True or False:

Gauzes, alcohol and swaps, insulin and insulin pens, are covered under part D.

True

400

What is the C/I for verification of Rx benefits calls?

Rx/ Benefits and copayments

400

What is the tool that you use to star a prior-authorization? 

PromtPA

400

What will be the call handling procedure for error code 488?

  • Attention: Don't direct the caller to Humana Clinical Pharmacy Review for clinical review.
  • .
  • • If the caller is a member, tell them that Humana has implemented safety restrictions designed to prevent patients from taking drugs with potentially harmful effects. They're receiving 1 or more drugs which are exceeding safety limits. They can consult their prescriber for additional information or be consult transferred to Opioid Case Management:
  • .
  • • Consult transfer the caller to Opioid Case Management at 1-800-895-1305 to request a clinical review.
  • .
  • • If the caller is the prescriber, advise the caller that you're consult transferring them to Opioid Case Management where they can speak to a clinical pharmacist to discuss the patient's current therapy. Consult transfer the caller to:
  • .
  • • Consult transfer the caller to Opioid Case Management at 1-800-895-1305 to request a clinical review.
  • .
  • • If the caller is the pharmacy, tell them:
  • .
  • - The member is restricted to a set Morphine Equivalent Edit limit.
  • - This edit isn't eligible for a PPS override.
  • - The patient or provider can call for additional information about the limit.
  • - Give the Opioid Case Management number.
  • .
  • • Consult transfer the caller to Opioid Case Management at 1-800-895-1305 to request a clinical review.
400

How can you describe a Specialty Drug?

High-cost drugs not commonly stocked at pharmacies due to special shipping or storage requirements.

400

True or False:

Members with CenterWell Pharmacy OTC benefits receive a visa card at the beginning of the year.

False

500

Probing Questions

member calls and ask: Is my medication covered?

What probing questions may you ask?

* What is the name of the medication?

* What is the dosage and frequency taken?

* What pharmacy do you prefer to use?

500

What are some reason a medication may require a prior-authorization, name 3?

*The state or federal government requires Humana to review certain prescriptions requests.

*A lower cost alternative medication may treat the same condition

*The medication may have side effects 

*The medication can be dangerous if taken with other medication

*The medication should only be taken for certain health conditions

*The medication is a controlled substance or is likely to be abused


500

That is the code 048 stands for?

non formulary drug

500

How can you describe controlled drugs?

Divided into schedules by the DEA based on accepted medical use, safety and abuse potential.

500

Mention 3 tools we used in our role as tier 1 agents.

Debut, RXconnect pro, Rx Nova connect, physician finder, evidence of coverage, benefit grid etc...