Humana Pharmacy Solutions® Pharmacy Manual Medicare and Commercial 2021 Edition GHHJT9NEN 0920 LC8121ALL1020 1 Table of contents Introduction ...................................................................................................................................... 4 Pharmacist portal ............................................................................................................................................................... 4 Rx Quality Network Program ............................................................................................................................................ 4 How to join our network .................................................................................................................................................... 4 Contact information ......................................................................................................................... 5 Eligibility verification ....................................................................................................................... 6 Humana member identification (ID) cards .................................................................................................................... 6 Humana Medicare Advantage-only plans ...................................................................................................................... 7 Cardholder ID ...................................................................................................................................................................... 8 Person code ......................................................................................................................................................................... 8 Medicare coverage determinations ................................................................................................................................. 8 Beneficiaries eligible for the low-income subsidy (LIS) ................................................................................................ 9 Best available evidence for long-term care residents ................................................................................................ 10 2021 low-income subsidy chart ..................................................................................................................................... 11 Drug coverage................................................................................................................................. 11 Drug Lists ........................................................................................................................................................................... 11 Exceptions to plan coverage for Medicare members ................................................................................................. 12 Utilization management (UM) ........................................................................................................................................ 12 General claims procedures ............................................................................................................ 13 Submitting pharmacy claims .......................................................................................................................................... 13 Bank Identification Numbers (BIN) and Processor Control Numbers (PCN) ............................................................ 13 Prescription origin code requirements .......................................................................................................................... 13 Fill number ......................................................................................................................................................................... 13 Sales tax ............................................................................................................................................................................. 14 Timely submission of claims ........................................................................................................................................... 14 Humana-specific SS&C Health payer sheets ................................................................................................................ 14 Prescriber NPI submission ............................................................................................................................................... 15 Dispense-as-written (DAW) codes ................................................................................................................................. 15 Drug utilization review (DUR) safety edits .................................................................................................................... 16 Soft reject DUR .................................................................................................................................................................. 17 Humana Access® Mastercard® Debit Card ................................................................................................................... 18 Controlled substances.................................................................................................................... 19 Controlled substance claims .......................................................................................................................................... 19 Clarification of federal requirements – Schedule II drugs ......................................................................................... 20 Submitting CII claims ...................................................................................................................................................... 20 Point-of-sale (POS) edits and overrides ........................................................................................................................ 20 Medicare claims coverage ............................................................................................................. 20 Medicare Part B vs. Part D coverage .............................................................................................................................. 20 Medicare Part B vs. Part D claims submission .............................................................................................................. 22 Medicare vaccine administration ................................................................................................................................... 22 Humana processing of Medicare drug exclusions ....................................................................................................... 22 Medicare continuity of care ............................................................................................................................................ 23 Level-of-care changes ..................................................................................................................................................... 23 Long-term care (LTC) ...................................................................................................................... 24 Long-term care pharmacy information ........................................................................................................................ 24 LTC claims-processing guidelines .................................................................................................................................. 24 Nebulizer solutions covered under Part D for LTC residents ...................................................................................... 25 2 Long-term care short-cycle dispensing ........................................................................................................................ 25 Combination pharmacies ................................................................................................................................................ 26 Copayments ...................................................................................................................................................................... 26 Long-term care attestation ............................................................................................................................................ 26 Home infusion billing procedures.................................................................................................. 27 Compound claims ........................................................................................................................... 27 Submitting compound claims ........................................................................................................................................ 27 Medication Therapy Management (MTM) program ...................................................................... 28 Pharmacy audit and compliance ................................................................................................... 28 Pharmacy audit program ................................................................................................................................................ 28 Long-term care pharmacy audits .................................................................................................................................. 29 Compliance program audits ..........................................................................................................................................