Welcome

P h a rm a c y P r o v i d e r M e d i c a r e P a r t D M a n u a l –Medicare –Group health –Individual health –Dental and Life www.humana.com Our vision is a new world of health care. At With Humana, employers and individuals alike Humana, we realize we ultimately serve individuals, are more satisfied with their health benefits one member at a time. Yet, traditionally, individuals experience. have been an afterthought in the health benefits system. It’s little wonder members think they have Humana Inc., headquartered in Louisville, no control over their own health care. Members Kentucky, is one of the nation’s largest publicly feel trapped in a maze – spending more to get less. traded health benefits companies, with And their employers feel the same. approximately 7 million medical members located primarily in 15 states and Puerto Rico. Humana Humana has an answer. In simple terms, we offer offers a diversified portfolio of health insurance a better experience and lower cost. We create an products and related services – through traditional environment where individuals learn to direct their and consumer-choice plans – to employer groups, own health care. And by serving the consumer, government-sponsored plans and individuals. we meet the needs of employers, as well. Our total solution is built on actionable information Over its 44-year history, Humana has consistently and fueled by individual empowerment. We help seized opportunities to meet changing customer consumers take control – by guiding them to draw needs. Today, the company is a leader in consumer on their purchasing skills and providing them with engagement, providing guidance that leads to tools to make informed decisions. lower costs and a better health plan experience throughout its diversified customer portfolio. The Humana Guidance Solution is proven to work. Humana integrates diverse products, health Please keep this manual handy as we hope it will resources, financial forecasting and consumer guide you into the world of Humana’s Medicare engagement to create the Humana Guidance Part D program. Solution. This unique solution blends technology, science and creative thinking – elements that Sincerely, interact to bring new freedom and flexibility to health care management.

William K. Fleming, PharmD Vice President, Pharmacy and Clinical Integration

2 Index

Index Humana Prescription Drug Plans ...... Page 4 Identification Cards ...... Page 6 BIN and Processor Control Numbers ...... Page 7 Claims Processing ...... Page 8 Prior Authorization...... Page 8 Maximum Dispensing Limits ...... Page 8 Step Therapy...... Page 8 Part B versus Part D ...... Page 9 Drug Exclusions ...... Page 10 Rejects ...... Page 10 Pill Splitting ...... Page 10 Diabetic Supplies...... Page 10 Coordination of Benefits ...... Page 11 Reversals ...... Page 15 Order of Claims ...... Page 15 Maximize your Benefit ...... Page 15 Coverage Determinations ...... Page 15 Exceptions to Plan’s Coverage...... Page 15 Medication Therapy Management ...... Page 16 Reimbursement Rates ...... Page 17 SmartSummary Rx...... Page 18 Phone Numbers and Web site ...... Page 20 Questions and Answers ...... Page 21

Appendices

Medicare Overview ...... Appendix A Low Income Subsidy Chart ...... Appendix B Humana Plan Designs ...... Appendix C Notice - Medicare Prescription Drug Coverage and Your Rights ...... Appendix D

3 Prescription Drug Plans

Humana has chosen to offer 3 types of stand-alone prescription drug plans. 1. Standard Plan – A basic plan, equal to the federal government’s minimum requirements 2. Enhanced Plan - Broad coverage with copayments to help manage costs instead of an upfront deductible 3. Complete Plan - Extensive coverage with no upfront deductible, low copayments and no coverage gap

Within the enhanced and complete plans, there is a four-category copayment differentiation among the cost levels.

Category 1 – Generic Drugs Category 2 – Preferred Brand-Name Drugs Category 3 – Nonpreferred Brand-Name Drugs Category 4 – Specialty Drugs

4 DETAILS of Humana’s Prescription Drug Plans

STANDARD PLAN ENHANCED PLAN COMPLETE PLAN $1.87 - $17.91 $4.91 - $25.36 $38.70 - $73.17 range of monthly range of monthly range of monthly plan premium** plan premium** plan premium**

Stage You pay $250 deductible Copayments until total Copayments until total drug costs reach $250: drug costs reach $250: 1 • Generics ...... $0 • Generics ...... $0 • Preferred ...... $30 • Preferred ...... $30 • Non-preferred ... $60 • Non-preferred ...$60 • Specialty ...... 25% • Specialty ...... 25% coinsurance coinsurance

Humana pays $0 Balance of costs Balance of costs Copayments until total Copayments until your You pay 25% of next $2,000 Stage of total drug costs drug costs reach $2,250: total out-of-pocket (= $500) • Generics ...... $7 costs reach $2,250: 2 • Preferred ...... $30 • Generics ...... $7 • Non-preferred ... $60 • Preferred ...... $30 • Specialty ...... 25% • Non-preferred ...$60 coinsurance • Specialty ...... 25% coinsurance

Humana pays 75% ($1,500) Balance of costs Balance of costs

Stage You pay Next $2,850 of total 100% until your total Copayments until your drug costs. (This brings out-of-pocket costs total out-of-pocket your total out-of-pocket reach $3,600 costs reach $3,600: 3 costs to $3,600) • Generics ...... $7 • Preferred ...... $30 • Non-preferred ...$60 • Specialty ...... 25% coinsurance

This is the coverage gap This is the coverage gap NO COVERAGE GAP

Humana pays $0 $0 Balance of costs

Stage You pay 5% coinsurance with 5% coinsurance with 5% coinsurance with a $2 or $5 minimum, a $2 or $5 minimum, a $2 or $5 minimum, 4 depending on the type depending on the type depending on the type of drug of drug of drug

Humana pays 95% of total drug costs 95% of total drug costs 95% of total drug costs for the rest of the year for the rest of the year for the rest of the year

**You must continue to pay Medicare applicable premiums. 5 Identification Cards The following are examples of the ID cards that you will see from our members who have Medicare prescription drug coverage.

Card for patient with Prescription Drug Plan (PDP)

Humana Prescription Drug Plan IMPORTANT NUMBERS: SAMPLECARDS, CHRISTOPHER S CUSTOMER SERVICE: 1-800-281-6918 Member ID: 12345678-9 Effective: 01/01/2006 TDD/TTY Hearing or Speech Impaired: 1-800-833-3301 Your Company Name Issuer: 80840 Pharmacist/Physician Rx Inquiries: 1-800-865-8715 Group: 87654321 RxBIN: 87654321 RxPCN: 1234 Submit claims to: Humana Claims, P.O. Box 14601, Lexington, KY 40512-4601.

www.humana.com CARD ISSUED: 03/27/2005 CMS S5884 001

(Front) (Back)

Card for patient with Medicare Advantage-Prescription Drug Coverage (MA-PD)

CUSTOMER SERVICE: 1-877-511-5000 TDD/TTY Hearing or Speech Impaired: 1-800-833-3301 Humana Gold Choice PFFS A Medicare Health Plan with Prescription Drug Coverage PROVIDERS: DO NOT BILL MEDICARE. For payment SAMPLECARDS, CHRISTOPHER S terms and conditions: 1-866-291-9714 Member ID: 12345678-9 Effective: 01/01/2006 Pharmacist/Physician Rx Inquiries: 1-800-865-8715 Your Company Name Issuer: 80840 Copayments Group: 87654321 Physician and hospital RxBIN: 87654321 OFFICE VISIT: $10 authorization or notifi cation: 1-800-523-0023 RxPCN: 1234 SPECIALIST: $30 HOSPITAL EMERGENCY: $50 Submit claims to: Humana Claims, PO Box 14601, Lexington, KY 40512-4601 www.humana.com CARD ISSUED: 03/27/2005 CMS H1234 001 (Front) (Back)

The number below the CMS logo (MedicareRx) Humana has entered into agreements with various corresponds to the member’s plan benefits. PDP chains (including Wal-Mart/Sam’s Club, CVS, Rite plans begin with an “S” alpha character. Please Aid and Brooks/Eckerd) for the purpose of driving refer to Appendix C for a listing of the PDP plans health literacy through the distribution of educational with the corresponding plan benefits. However, materials about Medicare 2006 to Medicare MA-PD plans begin with an “H” or “R” alpha beneficiaries. Therefore, a Medicare beneficiary character. Because of the wide variety of may present a prescription card with the logo(s) MA-PD plans, please refer to our Web site of a pharmacy displayed on the bottom left corner at www.humana.com for specific of the card. However, the Medicare beneficiary may plan information. go to any pharmacy participating within the Humana national network; the beneficiary is not limited to the pharmacy displayed on the card.

6 Identification Cards

Humana Medicare Advantage Only Plans Please be aware that not all Medicare beneficiaries will opt to participate in a Medicare PDP or MA-PD plan. Some beneficiaries may continue to only participate in the Medicare Advantage Plan (without the prescription benefit). The coverage for these beneficiaries includes a benefit for Part B drugs as well as a discount for Part D drugs. Note that the BIN and PCN numbers are not supplied on the identification cards. However, please continue to process claims for these members under BIN 610649 and PCN 03200000. Beneficiaries with this plan may present a card like either of these below.

Card for patient with MA only plan (HMO)

CUSTOMER SERVICE: 1-800-457-4708 TDD/TTY Hearing or Speech Impaired: 1-800-833-3301 Humana Gold Plus HMO Primary Physician/Center: XXX XXXXXXXXXXX Telephone: XXX XXX-XXXX A Medicare Health Plan SAMPLECARDS, CHRISTOPHER S Physician and hospital authorization or notifi cation: 1-800-523-0023 Member ID: 12345678-9 Effective: 01/01/2006 Copayments Submit claims to: Humana Claims, PO Box 14601, OFFICE VISIT: $10 Lexington, KY 40512-4601. SPECIALIST: $30 Supplemental Benefi ts: DEN723 / VIS734 / HER820 HOSPITAL EMERGENCY: $50 www.humana.com CARD ISSUED: 03/27/2005 CMS H1234 001

(Front) (Back)

Card for patient with MA only plan (PPO)

CUSTOMER SERVICE: 1-800-457-4708 TDD/TTY Hearing or Speech Impaired: 1-800-833-3301 Physician and hospital HumanaChoicePPO authorization or notifi cation: 1-800-523-0023 A Medicare Health Plan Submit claims to: Humana Claims, PO Box 14601, SAMPLECARDS, CHRISTOPHER S Lexington, KY 40512-4601. PPOM Providers: PPOM Claims, P.O. Box 2720, Member ID: 12345678-9 Effective: 01/01/2006 Farmington Hills, MI 48333-2720. Copayments OFFICE VISIT: $10 Supplemental Benefi ts: DEN723 / VIS734 / HER820 SPECIALIST: $30 www.humana.com CARD ISSUED: 03/27/2005 HOSPITAL EMERGENCY: $50

CMS H1234 001

(Front) (Back)

BIN and Processor Control Numbers • All claims are adjudicated through Argus. • The BIN and the Processor Control Number (PCN) for Non-Medicare: 610649/03190000 • The BIN and the Processor Control Number (PCN) for PDP, MA-PD, CarePlus Health Plans: 610649/03200000

7 Claims Processing Prior Authorization Certain drugs must undergo a criteria-based approval process prior to a coverage decision. The Pharmacy and Therapeutics Committee reviews medications based on safety, efficacy and clinical benefit and may make additions or deletions to the list of drugs requiring prior authorization.

For information on prior authorizations, visit our Web site at www.humana.com. For a prior authorization request, please have the member, the member’s authorized representative or the prescribing physician contact Humana Clinical Pharmacy Review (HCPR) at 1-800-555-CLIN (2546).

Maximum Dispensing Limits (MDLs) Humana has implemented a number of Maximum Dispensing Limits on various classes of drugs to facilitate appropriate approved label use of these agents. We believe this program will help members with obtaining the appropriate and optimal dose required for treating their condition. If a patient’s medical condition warrants additional quantity, please have the member, the member’s authorized representative or the prescribing physician contact Humana Clinical Pharmacy Review (HCPR) at 1-800-555-CLIN (2546).

Step Therapy The Medicare Prescription Drug Plan will be subject to step therapy protocols as a component of Humana’s standard Drug Utilization Review (DUR) program. Step therapy protocols require the member to try a particular drug (or drugs) before receiving another drug; in other words, members are required to utilize medications commonly considered first-line before using medications considered second- or third-line. These protocols are used to promote established national treatment guidelines. Additionally, step therapy protocols assist in promoting safe and cost-effective medication therapy. An example of a step therapy protocol is Humana’s COX II inhibitor step therapy. Members are required to try at least two nonselective NSAIDs or have a condition which places them at risk for complications or bleeding (i.e., advanced age, history of gastrointestinal bleed, taking a prescription PPI or H2RA, anti-platelet therapy, oral corticosteroid, bisphosphonate, warfarin, antineoplastic, and/or LMWH) before they can receive a COX II inhibitor.

If you have questions about a step therapy regimen, please have the member, the member’s authorized representative or the prescribing physician contact Humana Clinical Pharmacy Review (HCPR) at 1-800-555-CLIN (2546).

8 Claims Processing

Part B vs. Part D Billing Medicare Part B will continue to cover: • Oral immunosuppressive drugs secondary to a Medicare approved transplant • Oral anti-emetic drugs for the first 48 hours after chemotherapy • Cancer drugs • Inhalation drugs delivered through a nebulizer • Diabetic testing supplies, such as blood glucose monitors, test strips and lancets • Some drugs that are administered in the home setting that require the use of an infusion pump, such as certain antibiotics and pain medications.

Medicare Part D plans will cover: • Most legend drugs • Insulin • Insulin supplies, such as syringes, needles, gauze, alcohol, swabs, insulin pens and needle-free syringes • Vaccines • Prescription-based smoking cessation products • Injectable drugs and infusion drugs that can be self-administered or administered in the home setting, if they are not already covered under Medicare Part A or B • Drugs that are not already covered under Part B (or for an indication that might not be covered under Part B), such as infusion drugs that are delivered through a mechanism, such as a drip bag; intramuscular and intravenous drugs, such as antibiotics; pain management drugs; chemotherapy drugs; parenteral nutrition; immunoglobulin; and other infused drugs.

(Please note that this is not an all inclusive list of drugs covered under Part D).

Example 1: Phenergan may be dispensed to treat a patient’s nausea that is a result of chemotherapy. In this instance, Phenergan should be billed to Medicare Part B. However, if Phenergan is dispensed to treat a patient’s nausea that is a result of the flu, then the Phenergan should be billed to Medicare Part D.

Example 2: Prednisone may be prescribed as an immunosuppressive agent secondary to a Medicare approved transplant. In this instance, Prednisone should be billed to Medicare Part B. However, if Prednisone is dispensed to treat a patient’s asthma or arthritis, then the Prednisone should be billed to Medicare Part D.

Therefore, there are some drugs that may be covered under the Part B or the Part D plan depending upon the indication. PDP plans will cover Part D drugs. MA-PD plans will cover Part B and Part D drugs. However, a drug claim will never be eligible for coverage under Part B and Part D simultaneously.

So that these drugs are billed properly, Humana will require a preauthorization for prescription drugs in these categories. To obtain a preauthorization number, the member’s authorized representative or prescribing physician should contact Humana Clinical Pharmacy Review (HCPR) at 1-800-555-CLIN (2546). At this point, the Help Desk will determine if the diagnosis is appropriate for Part D and, if so, provide the prior authorization number.

9 Claims Processing

Drug Exclusions CMS has specifically excluded these categories of drugs from all Part D benefits: • Drugs used for anorexia, weight loss or weight gain, • Drugs used to promote fertility • Drugs used for cosmetic purposes or hair growth • Drugs used to treat the symptoms associated with a cold or a cough • Prescription vitamins and minerals, except prenatal vitamins and fluoride preparations • Over the counter drugs (nonprescription drugs), except insulin and supplies associated with the insulin injection (syringes, needles, swabs and gauze). • Benzodiazepines • Barbiturates

Note: for drugs that are excluded, if the patient does not have any secondary prescription coverage, such as Medicaid or a supplemental plan, you should still transmit the claim to Humana. The prescription claim will adjudicate through the discount network with 100 percent copayment from the beneficiary.

Rejects Call Argus Help Desk for assistance with the following reject messages: • Refill too soon • Missing/Invalid Cardholder ID • Missing/Invalid Group Number • Missing/Invalid Date of Birth • Invalid NDC • Invalid Days Supply

Pill Splitting Humana does not participate in, promote or endorse tablet-splitting programs for its members. After a comprehensive review of the topic, Humana has determined that tablet-splitting to control prescription drug costs is a subject that should be discussed between the member and his/her health care providers (physician or pharmacist), including an assessment of the potential risks versus benefits. Many medications are not suitable candidates for tablet-splitting and certain medical conditions may prevent patients from being able to split tablets effectively.

Diabetic Supplies Humana will cover insulin, insulin syringes/needles and alcohol swabs under Medicare Part D (MA-PD and PDP). However, there is a difference in the copayment, depending upon the product:

• Tier 2 – Humulin, Novolin and Lantus products • Tier 1 - Insulin syringe/needles and alcohol swabs will not require a concomitant insulin claim.

Blood glucose meters and strips are covered under Medicare Part B.

10 Claims Processing

Coordination of Benefits There are three main billing scenarios that you will see with Medicare beneficiaries. To help alleviate any confusion, upon claim transmission, Humana will communicate other insurance information in the response to the pharmacy. If available, the other insurance information will include the routing information, the toll-free number, etc.

Patient has Humana PDP or MA-PD only. ACTION Bill the Humana Medicare prescription benefit. No coordination of benefits is necessary.

11 Patient has a primary prescription insurance (usually an employee group health plan) and Humana PDP or MA-PD as a secondary insurance. ACTION Bill the primary insurance and then bill the copayment or the remaining amount the patient would pay to Humana.

If the primary insurance did not actually pay anything on the claim, process the prescription with copayment-only billing. Examples of copayment-only billing include when the member is still meeting the deductible or when processing a prescription through a discount card. To process a copayment-only claim, a value of “8” should be entered into the “Other Coverage Code” field (NCPDP field 308-C8) as shown below; the other fields listed below are not transmitted.

If the primary insurance paid an amount on the claim, then process the claim with the “Coordination of Benefits” segment. This scenario, the most common example of true Coordination of Benefits (COB), requires a value of “2” to be entered into the “Other Coverage Code” field (NCPDP field 308-C8). Other values may be entered (3 through 7) on those claims where the primary insurance denied the claim, but these will be the exception by far. The other fields listed below are the most common fields within the COB segment that may require an entry by the pharmacist (although many software systems auto-populate this information).

12 DESCRIPTION FIELD EXPLANATION OF FIELD ENTRY Other Insurance Field/ 2 Other coverage exists, payment collected Other Coverage Code (NCPDP field 308-C8) 3 Other coverage exists, this claim not covered 4 Other coverage exists, payment not collected

5 Managed care denial

6 Other coverage denied, not a participating provider

7 Other coverage exists, not in effect at time of service

8 Claim is billing for copayment (The primary insurance discounted the original amount but did not pay anything and you are billing for 100% copayment)

Other Paid Amount $XX.XX Dollar amount paid by the primary carrier (NCPDP field 431-DV) Other Payer ID Qualifier Qualifying ID of the primary insurance (NCPDP field 339) Other Payer ID Payer ID of the primary insurance (NCPDP field 340)

13 io ar n e c S

Patient has Humana PDP or MA-PD with a secondary insurance, such as Medicaid, a State Pharmacy Assistance Plan or a supplemental insurance plan. ACTION • If the patient is dual eligible, i.e., the patient has both Medicare and Medicaid, and if the drug is covered by the Medicare plan, the claim will adjudicate without any further billing. However, if the drug is not covered under Medicare (e.g. benzodiazepine and barbiturate), but is covered on the Medicaid formulary, you will need to adjudicate the claim through the Medicaid plan.

• If the secondary insurance is a State Pharmacy Assistance Plan (SPAP), the need for additional billing will depend upon how the SPAP is handling the adjudication process in their state. • Some SPAPs will process claims like Medicaid and will not require any further billing to a secondary payer. These SPAPs will reconcile with the Medicare PDP through periodic lump-sum payments. • Other SPAPs will process like a secondary payer, requiring the pharmacist to split bill the claim. • If the secondary is a supplemental insurance plan, bill Medicare and then bill the copayment or the remaining amount the patient would pay to the supplemental insurance.

Note: It is possible for a Medicare beneficiary to have three insurance plans, such as a primary insurance, Medicare, as well as a supplemental insurance. If that is the case, then the adjudication process will be a combination of both scenarios 2 and 3.

14 Claims Processing Reversals Because reversals of prescriptions affect the patient’s copayment and TrOOP balance, please make sure that you monitor the will-call bin and process unclaimed prescriptions on a timely basis.

Order of Claims Processing Please note that the order of processing multiple prescriptions may impact the total amount of out-of-pocket expense for the Medicare beneficiary, with the least expense to the customer occurring when the most expensive drug is submitted first. This may be more likely to occur in the Standard Plan.

Maximize Your Benefit With a tiered-copayment prescription drug benefit, members generally pay the lowest copayment for tier 1 drugs (generic drugs) and the highest copayment for tier 3 drugs (nonpreferred brand-name drugs).

The Maximize Your Benefit program helps members understand their tiered pharmacy benefit and ultimately helps them maximize ways they utilize their benefit. As this program helps the member decrease out-of-pocket costs by using 1st and 2nd tier drugs, it should also help decrease overall medical expenses by using these more cost-effective products.

A list of high-volume, high-cost 3rd tier drugs has been compiled. Members receiving prescriptions for these drugs will receive a letter that clarifies their prescription drug benefit and advises them that an alternative drug that may be as effective is available to them at a lower 1st or 2nd tier copayment that could reduce the member’s out-of-pocket expense by up to 50 percent.

In the letter, we will encourage members to talk to their doctor about their benefits and the alternatives available to them for the particular therapeutic class, as defined by a national standard. This will allow the doctor and member/patient to talk about different treatment options relative to what the member is willing to pay for health care.

The letter will be generated within a week of the prescription being filled. It will list the name of the drug the member is taking and the name/names of the alternatives on the Drug List. It is our expectation that with the experience of paying the 3rd tier copayment still fresh in their minds, members will be more likely to contact their physician about an alternative medication.

If the doctor agrees and the member switches to the 1st or 2nd tier alternative in only 10 percent of the cases, both the member and the health care system will realize decreased costs.

Coverage Determinations Members have the right to ask Humana to make a decision regarding the coverage of a drug or reimbursement for a drug purchased out-of-pocket or purchased at an out-of-network pharmacy.

15 Claims Processing Members and physicians can request an expedited coverage determination if the member’s health would be placed in jeopardy by waiting the standard 72 hours for a decision. However, requests for payment or reimbursement cannot be expedited.

Members and physicians may request a coverage determination or expedited coverage determination by calling 1-800-865-8715.

Exceptions to Plan’s Coverage Members can ask Humana to make an exception to our coverage rules. There are several types of exceptions members can request:

• Request for a drug to be covered even if it is not on our formulary; • Request that Humana waive coverage restrictions or limits on a drug (prior-authorization, step-therapy, dispensing-limit restrictions); • Request a higher level of coverage for a drug. For example, if a drug is considered a Tier 3 drug, the member can ask for it to be covered as a Tier 2 drug instead (lower copayment for member).

Generally, we will only approve an exception request if the alternative drugs included on the formulary or the lower-tiered drug would not be as effective in treating the member’s condition and/or would cause the member to have adverse effects.

A member may request an exception from Humana; however, the request must be supported by the member’s physician in a supporting statement.

A member may request an expedited exception if his/her health would be placed in jeopardy by waiting the standard 72 hours for a decision.

Members and physicians can request an exception or an expedited exception by calling 1-800-865-8715.

Medication Therapy Management Medication Therapy Management (MTM) is a distinct group of services that optimize therapeutic outcomes for individual patients and is a requirement for Medicare 2006. All plans that offer the new Medicare drug benefit are required to offer Medication Therapy Management Programs (MTMP). The aim of MTMP is to optimize medication therapy and to minimize adverse drug reactions. CMS has only defined one eligibility criterion for MTM (anticipated drug spend) and has allowed the plans to determine the number of medications and disease states required for eligibility into MTM services. As a result, you may see a wide variety of programs since CMS has allowed a great deal of flexibility in the eligibility and design of these programs. Humana believes that CMS has provided a great opportunity for health plans to educate members on their health status and improve their health literacy. With these goals in mind we have set the following criteria for eligibility into our MTM programs:

16 Claims Processing

1. Beneficiaries who have an anticipated incurred cost of $4,000 or greater in a calendar year (CMS criteria) 2. Beneficiaries who have at least two disease states as determined by the health plan 3. Beneficiaries who are on eight or more unique medications (some restrictions apply) in a 90-day period as determined by the health plan

Furthermore CMS has stated that MTM-eligible members will not be responsible for any direct cost-share for these services. The cost associated with these programs will be incurred by the health plan.

Humana has designed unique programs for 2006 that utilize a variety of resources, such as health literacy mailings, call centers and the knowledge of trained health care professionals to improve members’ health literacy and optimize therapy with the intent of minimizing adverse drug reactions. The pharmacy must be enrolled with the MTM network in order to receive reimbursement.

Reimbursement Rates There are several contracts within the pharmacy network. If your pharmacy has signed a contract for 30-day reimbursement, all claims will adjudicate at the 30-day reimbursement rate.

If your pharmacy has signed a contract for 30-day and 90-day reimbursement, claims with days supply of 1 to 30 will be reimbursed at the 30-day rate, and claims with days supply of 31 to 90 will be reimbursed at the 90-day rate.

If you have not signed up for the “90-day at retail” program, please fax us at (502) 580-2200 to request a contract.

17 An Introduction to Humana’s SmartSummary RxSM Members of Humana’s Medicare Part D program By compiling a record of the member’s prescription will also receive a valuable new tool that can help drugs, over-the-counter medicines and information you and them better manage their prescriptions. about office samples all in one place, this monthly Starting in February 2006, Humana will begin statement can help facilitate drug safety and sending SmartSummary Rx (see image below) continuity of care. to all Medicare Part D prescription drug plan members.

Included in the patent-pending SmartSummary Rx is an “Rx Manager,” (see graphic on following page) detailing drugs the member is taking, refill dates, side effects, drug interactions and more.

This personalized monthly statement can also help members understand how their Humana Prescription Drug Plan works. Monthly ‘you-are-here’ plan maps show the member’s actual claims data to illustrate plan function and can help you more confidently answer questions they may have about their benefits.

SmartSummary © 2005 Humana Inc., Patent Pending

18 SM SmartSummary Rx will:

• Help members better understand the details of • Better prepare members to manage future health their prescription drug plan and feel more care spending with an easy-to-read statement that confident in the decisions they make regarding enables them to view all of their prescription drug their health and health care spending. spending in one place.

• Give members more confidence in their • Provide personalized messaging that will highlight interactions with you by providing them with a potential savings opportunities members can take portable “Rx Manager” they can use to talk about advantage of in the future. their prescriptions and health care.

Want to Learn More? If you would like to learn more about SmartSummary Rx, please contact us at the e-mail address below and we’ll send you an informational packet that includes a sample SmartSummary Rx statement. E-mail us at: [email protected].

19 Important Phone Numbers and Web Site Information

WEB SITE PHONE NUMBER

HUMANA www.humana.com 1-800-845-1265 8 a.m. – 11 p.m. EST Seven days a week

TDD: 1-877-833-4486 7 a.m. to 7 p.m. Monday through Friday

HUMANA MEMBER 1-800-4HUMANA (1-800-448-6262) CUSTOMER SERVICE In Puerto Rico, 1-800-256-3316

HUMANA CLINICAL 1-800-555-CLIN (1-800-555-2546) PHARMACY REVIEW (HCPR) HUMANA PHARMACY Fax: (502) 580-2200 NETWORK CONTRACTING HUMANA PDP CUSTOMER 1-800-281-6918 SERVICE (CURRENT AND PROSPECTIVE MEMBERS) HUMANA MA-PD CUSTOMER 1-800-457-4708 SERVICE (CURRENT MEMBERS) HUMANA MA-PD CUSTOMER 1-800-833-2364 SERVICE (PROSPECTIVE MEMBERS) HUMANA ETHICS HELP LINE 1-877-5THEKEY (1-877-584-3539)

HUMANA HELP DESK (ARGUS, 1-800-865-8715 CLAIMS PROCESSOR) 1-800-Medicare;(1-800-633-4227) CENTERS FOR MEDICARE AND www.medicare.gov (TTY 1-877-486-2048) MEDICAID SERVICES 24 hours a days, 7 days a week

YOUR GUIDE TO MEDICARE This free booklet is available upon request PRESCRIPTION DRUG COVERAGE by contacting 1-800-MEDICARE. It is CMS publication #11109.

SOCIAL SECURITY www.socialsecurity.gov 1-800-772-1213 ; TTY: 1-800-325-0778 ADMINISTRATION or www.ssa.org 7 a.m. to 7 p.m. Monday through Friday

STATE HEALTH INSURANCE Every state has a SHIP office to assist ASSISTANCE PROGRAM (SHIP) Medicare beneficiaries and their families with health insurance choices and with problems that may arise related to insurance coverage. Phone numbers and Web sites are specific to each state agency.

PARTNERSHIP FOR www.pparx.org 1-888-4PPA-NOW (1-888-477-2669) PRESCRIPTION ASSISTANCE Questions and Answers

Q: What do I do if a Medicare beneficiary shows up in my pharmacy WEB SITE PHONE NUMBER saying that he has enrolled in Medicare Part D but does not have any other information? A: Send an ‘eligibility check’ transaction to NDC Health. If you do not know how to HUMANA www.humana.com 1-800-845-1265 8 a.m. – 11 p.m. EST do this, check with your pharmacy software vendor for the procedure. To perform Seven days a week an eligibility check, you will need this information from the patient: • First Name TDD: 1-877-833-4486 • Last Name 7 a.m. to 7 p.m. • Date of Birth Monday through Friday • Gender • ZIP Code HUMANA MEMBER 1-800-4HUMANA (1-800-448-6262) • One of the following: CUSTOMER SERVICE In Puerto Rico, 1-800-256-3316 • ID number from Medicare Part A card • ID number from Medicare Part B card HUMANA CLINICAL 1-800-555-CLIN (1-800-555-2546) • Last 4 digits of the Social Security Number PHARMACY REVIEW (HCPR) NDC Health will respond with the appropriate information for all payers that this HUMANA PHARMACY Fax: (502) 580-2200 NETWORK CONTRACTING beneficiary has (primary and secondary). • Insurance Level HUMANA PDP CUSTOMER 1-800-281-6918 • “PRIMARY” for primary insurance SERVICE (CURRENT AND • “ADDINS” for secondary insurance PROSPECTIVE MEMBERS) • BIN and Processor Control Number HUMANA MA-PD CUSTOMER 1-800-457-4708 • Help Desk Phone Number SERVICE (CURRENT MEMBERS) • Cardholder ID HUMANA MA-PD CUSTOMER 1-800-833-2364 • Group Number SERVICE (PROSPECTIVE MEMBERS) • Person Code

HUMANA ETHICS HELP LINE 1-877-5THEKEY (1-877-584-3539) Q: What happens if a customer shows up with a Humana card, but I get a HUMANA HELP DESK (ARGUS, 1-800-865-8715 reject saying that the customer is not covered? CLAIMS PROCESSOR) A: The pharmacy should call the Argus help desk. If the patient has not been loaded 1-800-Medicare;(1-800-633-4227) to Argus, Argus will forward the call to the Humana customer service desk. CENTERS FOR MEDICARE AND www.medicare.gov (TTY 1-877-486-2048) MEDICAID SERVICES 24 hours a days, 7 days a week Q: What if a U.S. Senior is in my store and that individual wants to sign up for Humana’s PDP or MA-PD? What should I do? YOUR GUIDE TO MEDICARE This free booklet is available upon request A: Please provide the customer with the Humana Medicare Part D brochure. PRESCRIPTION DRUG COVERAGE by contacting 1-800-MEDICARE. It is CMS The individual may also go to www. Humana.com or call 1-800-845-1265, publication #11109. 8 a.m. – 11 p.m. EST, seven days a week or TDD: 1-877-833-4486, 7 a.m. to 7 p.m., Monday through Friday. SOCIAL SECURITY www.socialsecurity.gov 1-800-772-1213 ; TTY: 1-800-325-0778 ADMINISTRATION or www.ssa.org 7 a.m. to 7 p.m. Monday through Friday Q: Where can an enrollee go to learn more about the different plans that Humana has to offer and what is the best option? STATE HEALTH INSURANCE Every state has a SHIP office to assist A: An enrollee can go to www. Humana.com or call 1-800-845-1265, 8 a.m. – ASSISTANCE PROGRAM (SHIP) Medicare beneficiaries and their families with 11 p.m. EST, seven days a week or TDD: 1-877-833-4486, 7 a.m. to 7 p.m., health insurance choices and with problems that may arise related to insurance coverage. Phone Monday through Friday. numbers and Web sites are specific to each state agency.

PARTNERSHIP FOR www.pparx.org 1-888-4PPA-NOW (1-888-477-2669) PRESCRIPTION ASSISTANCE 21 Questions and Answers

Q: What do I do if a customer says that he/she qualifies for the low-income subsidy, but is not receiving it? A: Customers who believe that they qualify for the low-income subsidy should contact the Social Security Administration at 1-800-772-1213. If they have received confirmation from the Social Security Administration, but the system is not calculating the right cost- sharing amount, call Humana Customer Service at 1-800-4HUMANA (1-800-448-6262); in Puerto Rico, call 1-800-256-3316.

Q: What do I do if a customer says that the amount charged for his/her prescription is incorrect? A: Call Humana Customer Service at 1-800-4HUMANA (1-800-448-6262); in Puerto Rico, call 1-800-256-3316.

Q: Can an individual sign up the day before his/her coverage begins? A: If Humana receives/processes an individual’s completed application between November 15, 2005, and December 31, 2005, the individual’s effective date will be January 1, 2006. If the individual completes an application after January 1, 2006, the effective date will be the first of the month following the month of receipt. For example: if the individual completes an application on January 14, 2006, the effective date will be the February 1, 2006.

Q: Will Humana guarantee coverage for members who are not active in the system? A: If a prescription is presented in which the eligibility of the individual or the coverage of the product cannot be obtained, an emergency supply of medication (48 to 72 hour supply) should be provided to the member, which will be guaranteed by Humana.

Q: What do I do if a customer wants to know his/her TrOOP balance? A: Information regarding the TrOOP balance is not transmitted to the pharmacy. Therefore, if a patient has questions about his/her TrOOP balance, please refer him/her to the Humana Help Desk at 1-800-865-8715.

Q: How is the TrOOP balance calculated? A: Expenditures paid for by the beneficiary, another person, such as a family member, a qualified State Pharmaceutical Assistance Program (SPAP), or a qualified charity count toward the TrOOP balance. Expenditures paid for by another group health plan or another third-party arrangement does not count toward the TrOOP balance. Also, payment for drugs excluded by the Medicare Part D benefit does not count toward the TrOOP balance.

22 Questions and Answers Q: If I have a customer who wants to appeal Humana’s decision regarding his prescription claim, to whom do I refer him? A: The first level of appeal is a redetermination. Redetermination requests must be submitted in writing within 60 days from the date on the notice of Humana’s initial decision to:

Humana Standard PDP P.O. Box 14546 Lexington, KY 40512-4546

Humana can extend the 60-day time frame if the member has a good reason for missing the deadline. Humana will notify the member by letter within seven days of the outcome of the redetermination. An expedited redetermination can be requested by the member or the physician if waiting for a standard decision (seven days) could seriously harm the health or the ability of the member to function. To file an expedited appeal, call Humana at 1-800-867-6601 or fax it to 1-800-949-2961. The redetermination will be decided as expeditiously as the member’s health requires, but no later than 72 hours from receipt of the request.

23 Appendix A - Medicare Overview

Medicare The Centers for Medicare and Medicaid Services (CMS) is the federal agency that administers the Medicare Program. Currently, Medicare provides coverage to approximately 42 million Americans. Medicare is the national health insurance program for:

• People age 65 or older • Some people under age 65 with disabilities • People with End-Stage Renal Disease (ESRD), which is permanent kidney failure requiring dialysis or a kidney transplant.

The Medicare Modernization Act of 2003 provided for the implementation of a landmark change in the health benefits coverage of seniors – a prescription drug benefit – as of January 2006.

Definitions The following are important definitions regarding the Medicare drug benefit.

Medicare Part A is the traditional Medicare program that provides for hospitalization services.

Medicare Part B provides for physician services, outpatient hospital services, certain home health services and durable medical equipment.

Medicare Part D will provide the new Medicare prescription drug benefit. The stand-alone prescription drug plans are called prescription drug plans (PDPs). Individuals who are entitled to Medicare Part A or who are enrolled in Medicare Part B are eligible to participate in a PDP.

Another option for those beneficiaries who wish to have all of their medical benefits “under one roof” is Medicare Part C, or more commonly referred to as the Medicare Advantage program. This program combines the hospitalization, physician and prescription benefits under Medicare parts A, B and D. The prescription drug benefit under this plan is called the Medicare Advantage/Prescription Drug (MA-PD) plan. Individuals who are entitled to Medicare Part A and enrolled in Medicare Part B as well as reside within the service area are eligible to participate in an MA-PD.

A basic PDP will consist of the following:

• $250 annual deductible ($250 out of pocket); • 25 percent beneficiary cost-sharing between $250.01 and $2,250 in total prescription drug spending ($500 out of pocket); • 100 percent beneficiary cost-sharing between $2,250.01 and $5,100 ($2,850 out-of-pocket). This is commonly referred to as the coverage gap. • Adding these three drug expenditures gives the beneficiary’s true out-of-pocket spending, also known as TrOOP ($3,600 total out-of-pocket for Medicare Part D drug coverage).

24 Appendix A - Medicare Overview • Reduced beneficiary cost-sharing (catastrophic coverage) after reaching $5,100 in total prescription drug spending (copayment equal to the greater of $2 for a generic drug or a preferred multiple-source brand drug or $5 for other drugs, or 5 percent). • See the illustration below.

How the basic coverage of the Medicare prescription drug plan works

MEMBER PAYS $0 PLAN PAYS

First, members pay a yearly deductible Nothing at this point. of $250. This means the member must spend $250 on their prescription drugs before the drug benefit starts.

Then, members $250 The drug plan pay only 25 pays 75 percent % percent of the % of the total 25 cost of their 75 drug costs drugs until their drug costs for the year until the total drug costs for the year reach $2,250. This $2,250 is the total reach $2,250. cost of the members drugs, not just their out-of-pocket costs.

After that, the member pays 100 $2,250 Nothing at this point. percent of the drug costs (from $2,250 to $5,100). In other words, the member pays the next $2,850. $5,100

Then, the member pays The drug plan * five percent of the drug pays 95 percent % costs (or a small % of the cost 5 copayment) for the rest 95 of the drugs of the calendar year. after the member spends $3,600 in a calendar year.

*The greater of $2 for a generic drug or a preferred multiple-source brand drug or $5 for other drugs or 5%.

25 Appendix B - Low Income Subsidy Chart

Patients with limited income may qualify for a subsidy of the premium, deductible or copay (full and partial). See the chart below.

Copayment Copayment Above Deductible up to Out-of- Out-of-Pocket Pocket Limit Limit

Full Benefit Dual Eligibles $0 Generic $0 Generic $0 (Institutionalized) Brand $0 Brand $0

Full Benefit Dual Eligibles at or below $0 Generic $1 Generic $0 100% of Federal Poverty Level (FPL) Brand $3 Brand $0

Full Benefit Dual Eligibles above $0 Generic $2 Generic $0 100% of FPL Brand $5 Brand $0

Partial Benefit Dual Eligibles with incomes $0 Generic $2 Generic $0 below 135% of FPL (w/assets up to $6K/ Brand $5 Brand $0 Indiv or $9K/Couple)

Partial Benefit Dual Eligibles with incomes $50 15% Coinsurance Generic $2 below 135% of FPL AND (w/assets Brand $5 between $6K and $10K/Indiv or $9K and $20K /Couple)

Income from 135% to 150% FPL (w/ $50 15% Coinsurance Generic $2 assets that do not exceed $10K Indiv Brand $5 and $20K Couple)

26 Appendix C - Humana Plan Designs

Benefit A (Complete Plan) $0/$30/$60/25% from $0 to $250; $7/$30/$60/25% from $251 to $2250; $7/$30/$60/25% from $2251 to $5100; 5%/5%/5%/5% from $5101 to Unlimited

S5552-002 S5884-041 S5884-052 S5884-031 S5884-042 S5884-053 S5884-032 S5884-043 S5884-054 S5884-033 S5884-044 S5884-055 S5884-034 S5884-045 S5884-056 S5884-035 S5884-046 S5884-057 S5884-036 S5884-047 S5884-058 S5884-037 S5884-048 S5884-059 S5884-038 S5884-049 S5884-060 S5884-039 S5884-050 S5884-040 S5884-051

Benefit B (Enhanced Plan) $0/$30/$60/25% from $0 to $250; $7/$30/$60/25% from $251 to $2250; 100%/100%/100%/100% from $2251 to $5100; 5%/5%/5%/5% from $5101 to Unlimited

S5552-001 S5884-011 S5884-022 S5884-001 S5884-012 S5884-023 S5884-002 S5884-013 S5884-024 S5884-003 S5884-014 S5884-025 S5884-004 S5884-015 S5884-026 S5884-005 S5884-016 S5884-027 S5884-006 S5884-017 S5884-028 S5884-007 S5884-018 S5884-029 S5884-008 S5884-019 S5884-030 S5884-009 S5884-020 S5884-010 S5884-021

Benefit C (Standard Plan) Annual Deductible: $250; Coinsurance: 25% of Rx costs from $251 to $2250; Coverage Gap: 100% of Rx costs from $2251 to $5100; Catastrophic Coverage: 5% of Rx costs from $5101 to Unlimited S5552-003 S5884-071 S5884-082 S5884-061 S5884-072 S5884-083 S5884-062 S5884-073 S5884-084 S5884-063 S5884-074 S5884-085 S5884-064 S5884-075 S5884-086 S5884-065 S5884-076 S5884-087 S5884-066 S5884-077 S5884-088 S5884-067 S5884-078 S5884-089 S5884-068 S5884-079 S5884-090 S5884-069 S5884-080 S5884-070 S5884-081 27 Appendix D - Medicare Prescription Drug NOTES: Coverage and Your Rights You have the right to get a written • Refer to the benefits booklet you explanation from your Medicare drug received from your Medicare drug plan if: plan or call 1-800-MEDICARE to learn • Your doctor or pharmacist tells you that how to contact your drug plan. your Medicare drug plan will not cover • When you contact your Medicare drug a prescription drug in the amount or plan, be ready to tell them: form prescribed by your doctor. • You are asked to pay a different 1. Name the prescription drug(s) that cost-sharing amount than you think you believe you need. you are required to pay for a prescription drug. 2. Give the name of the pharmacy or physician who told you that the The Medicare drug plan’s written prescription drug(s) is not covered. explanation will give you the specific reasons why the prescription drug is not 3. State the date you were told covered and will explain how to request that the prescription drug(s) is an appeal if you disagree with the drug not covered. plan’s decision. According to the Paperwork Reduction You also have the right to ask your Act of 1995, no persons are required to Medicare drug plan for an exception if respond to a collection of information one of the two situations exists: unless it displays a valid OMB (Office of Management and Budget) control • You believe you need a drug that is number. The valid OMB control number not on your drug plan’s list of covered for this information collection is 0938- drugs. (The list of covered drugs is called NEW. The time required to distribute this a “formulary.”) information collection once it has been • You believe you should get a drug you completed is one minute per response, need at a lower cost-sharing amount. including the time to select the preprinted form and hand it to the enrollee. If What you need to do: you have any comments concerning • Contact your Medicare drug plan to ask the accuracy of the time estimates or for a written explanation about why a suggestions for improving this form, prescription is not covered or to ask please write to: for an exception if you believe you need a drug that is not on your drug plan’s CMS formulary or believe you should get a 7500 Security Boulevard drug you need at a lower Attn: PRA Reports Clearance Officer, cost-sharing amount. Baltimore, Maryland 21244-1850.

28 Appendix D - Medicare Prescription Drug NOTES:

Coverage and Your Rights

29 GH19208PR (12/9/2005) 12/05