01/15/2024

Humana

Aetna Managed Care Committee Member

Mary Stubitsch - Newland Medical Associates

Humana is Updating Their Pharmacy Point of Sale Safety Edits Effective January 1, 2024
Humana Pharmacy Solutions® employs several point-of-sale safety edits, prompting additional safety reviews to determine if prescribed medications are appropriate and medically necessary. Dispensing pharmacists should utilize their clinical knowledge and judgment to resolve and override with the updated drug utilization review (DUR)/professional pharmacy service (PPS) codes and new International Classification of Diseases, 10th revision {ICD-10) diagnosis code entry overrides. For additional information, please refer to the 2024 Humana Pharmacy Manual.

DUR/PPS code functionality allowed
Claims will display the message "Soft Reject Payer Allows DUR/PPS Code Override" in the National Council for Prescription Drug Programs {NCPDP) field. Based on the type of safety edit, use the charts below to enter the correct "Reason for service," "Professional service" and "Result of service" codes for successful claim adjudication. The steps for review include:

1. Review pharmacy records to identify the reason for rejection (therapeutic duplication, interactions, inappropriate dosage). Rejections may result due to multiple edits occurring concurrently.
2. Consult with the patient or their prescriber to confirm the appropriateness of the prescribed medications and determine current medications to exclude any therapy changes.
3. If pharmacy data and/or the prescriber/patient confirms appropriateness of the prescribed drug therapy and the pharmacist approves the prescription fill, override the rejection as indicated below.

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Vial Size Optimization Reminders and Tips
When a physician, hospital, or other provider or supplier must discard the remainder of a vial or combination of vials after administering a dose/quantity of a drug or biological to a Medicare patient, Humana provides payment for the discarded drug or biological amount as well as the dose administered, up to the amount of the drug or biological as indicated on the vial or package label. And as costs of expensive infusible and injectable drugs and biologics continue to rise, patients are also incurring higher out-of-pocket expense.

But one method that you can employ to minimize drug waste is vial size optimization (VSO). Vial size optimization occurs when a single vial or vial combination that generates the least amount of waste,
(given available vial sizes) is used.

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