COVERED DRUGS
Both Humana and the member pay medication costs until the shared total equals the member's TrOOP. Members are responsible for copayments and coinsurance.
Stage 2 = Initial Coverage
Humana prescription drug plans only cover medications that are on the Humana drug list.
Non-Formulary
Certain drugs may require pre-approval from Humana to be eligible for coverage and to determine if the drug is the most cost effective and appropriate treatment.
Prior Authorization
To prevent any interruption in medication treatment, pharmacists may dispense up to the quantity limit while HCPR completes their review.
Access to Care
Glucose meters are handheld devices which use test strips to measure glucose levels after using a lancing device to puncture the skin and draw blood
Glucose test meters
CenterWell Pharmacy provides personalized pharmacy care to help our members get to their best health.
Mail Order
Mark can't afford his medication switching from a T2 to a T3 drug next year.
Tier Exception
A prior authorization is required to determine whether the medication is covered under the medical or pharmacy benefit.
Part B vs D
CSP works closely with doctors to help members stay on track with their treatment and offer suggestions to help manage medication side-effects.
Personal Guidance
Members using a glucose meter must have _________ available in order to check their sugar levels
Test Strips
The status of a ______ is found the same way you verify the status of a prior authorization. Access the CRM Authorization/Referral Summary tab.
COVERAGE DETERMINATION
In what tool we are using if Prescription drug benefit information is confirmed in _____?
Rx Connect Pro
Certain medications may have Maximum Dispensing Limits (MDL) restricting the amount that is covered. Quantity limits define how much medication can be filled during a specific time period.
Dosing Limits
Specialty medications arrive in plain packaging to protect the member’s privacy. Supplies needed to administer the drug such as syringes are provided at no additional cost.
Confidential and Safe Delivery
Oral medication or insulin is a must to manage it.
Develops over the course of many years
Type 2 Diabetes
All authorizations are entered by Generic Code Number (GCN) therefore, medications appear in RxNova under their generic name. This means if a brand drug is filled, the drug name in the member’s Claims History may not always match the drug found on the Auth Results page.
Brand and Generic Names
Debra's non-covered drug is too expensive and there's no alternative available
Drug List Exception
What tool do we need to utilize when checking if the medication has restriction?
RX connect pro
Drugs can be office administered or self-administered.
Specialty Injectable Drugs
People with diabetes are at increased risk of foot infections.
Diabetic Foot Care
Members who cannot afford their covered medications will be looking for help in reducing their out-of-pocket cost.
Tier Exceptions
Lyla received a letter stating her medication isn't on the 2024 drug list.
Drug List Exception
What can of medication can the members can only obtain a 7 days supply for their first fill only.
Opioid medication
Specialty medication that will treat arthritis.
Humira
___________ look similar to ink pens and are available in disposable or refillable varieties.
Insulin Pen