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Pharmacy Provider Medicare Part D Manual

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Our vision is a new world of health care. At Humana, we realize we ultimately serve individuals, one member at a time. Yet, traditionally, individuals have been an afterthought in the health benefits system. It’s little wonder members think they have no control over their own health care. Members feel trapped in a maze – spending more to get less. And their employers feel the same.

Humana has an answer. In simple terms, we offer a better experience and lower cost. We create an environment where individuals learn to direct their own health care. And by serving the consumer, we meet the needs of employers, as well. Our total solution is built on actionable information and fueled by individual empowerment. We help consumers take control – by guiding them to draw on their purchasing skills and providing them with tools to make informed decisions.

The Humana Guidance Solution is proven to work. Humana integrates diverse products, health resources, financial forecasting and consumer engagement to create the Humana Guidance Solution. This unique solution blends technology, science and creative thinking – elements that interact to bring new freedom and flexibility to health care management.

With Humana, employers and individuals alike are more satisfied with their health benefits experience.

Humana Inc., headquartered in Louisville, Kentucky, is one of the nation’s largest publicly traded health benefits companies, with approximately 7 million medical members located primarily in 15 states and Puerto Rico. Humana offers a diversified portfolio of health insurance products and related services – through traditional and consumer-choice plans – to employer groups, government-sponsored plans and individuals.

Over its 44-year history, Humana has consistently seized opportunities to meet changing customer needs. Today, the company is a leader in consumer engagement, providing guidance that leads to lower costs and a better health plan experience throughout its diversified customer portfolio.

Please keep this manual handy as we hope it will guide you into the world of Humana’s Medicare Part D program.

Sincerely,

William K. Fleming, PharmDVice President, Pharmacy and Clinical Integration

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IndexIndex

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

Appendices

Medicare Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Appendix ALow Income Subsidy Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Appendix BHumana Plan Designs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Appendix CNotice - Medicare Prescription Drug Coverage and Your Rights . . . . . . . Appendix D

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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 requirements2. Enhanced Plan - Broad coverage with copayments to help manage costs instead of an upfront deductible3. 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 DrugsCategory 2 – Preferred Brand-Name DrugsCategory 3 – Nonpreferred Brand-Name DrugsCategory 4 – Specialty Drugs

Prescription Drug Plans

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ENHANCED PLAN$4.91 - $25.36

range of monthlyplan premium**

COMPLETE PLAN$38.70 - $73.17range of monthly plan premium**

STANDARD PLAN$1.87 - $17.91

range of monthlyplan premium**

$250 deductible

$0

25% of next $2,000 of total drug costs(= $500)

75% ($1,500)

Next $2,850 of total drug costs. (This brings your total out-of-pocket costs to $3,600)

This is the coverage gap

$0

5% coinsurance witha $2 or $5 minimum, depending on the typeof drug

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

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

Balance of costs

Copayments until total drug costs reach $2,250:• Generics ............ $7• Preferred ........... $30• Non-preferred ... $60• Specialty ............ 25% coinsurance

Balance of costs

100% until your total out-of-pocket costs reach $3,600

This is the coverage gap

$0

5% coinsurance witha $2 or $5 minimum, depending on the typeof drug

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

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

Balance of costs

Copayments until your total out-of-pocket costs reach $2,250:• Generics ............$7• Preferred ...........$30• Non-preferred ...$60• Specialty ............. 25% coinsurance

Balance of costs

Copayments until your total out-of-pocket costs reach $3,600:• Generics ............$7• Preferred ...........$30• Non-preferred ...$60• Specialty ............. 25% coinsurance

NO COVERAGE GAP

Balance of costs

5% coinsurance witha $2 or $5 minimum,depending on the typeof drug

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

Stage

1

Stage

2

Stage

3

Stage

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DETAILS of Humana’sPrescription Drug Plans

You pay

Humana pays

You pay

Humana pays

You pay

Humana pays

You pay

Humana pays

**You must continue to pay Medicare applicable premiums.

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Identification CardsThe 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)

(Front) (Back)

Humana Prescription Drug Plan

CMS S5884 001

IMPORTANT NUMBERS:

CUSTOMER SERVICE: 1-800-281-6918

TDD/TTY Hearing or Speech Impaired: 1-800-833-3301

Pharmacist/Physician Rx Inquiries: 1-800-865-8715

Submit claims to: Humana Claims, P.O. Box 14601, Lexington, KY 40512-4601.

www.humana.com CARD ISSUED: 03/27/2005

Member ID: 12345678-9Your Company NameGroup: 87654321RxBIN: 87654321RxPCN: 1234

Effective: 01/01/2006Issuer: 80840

SAMPLECARDS, CHRISTOPHER S

Humana Gold Choice PFFSA Medicare Health Plan with Prescription Drug Coverage

CMS H1234 001

CUSTOMER SERVICE: 1-877-511-5000TDD/TTY Hearing or Speech Impaired: 1-800-833-3301

PROVIDERS: DO NOT BILL MEDICARE. For payment terms and conditions: 1-866-291-9714

Pharmacist/Physician Rx Inquiries: 1-800-865-8715

Physician and hospital authorization or notifi cation: 1-800-523-0023

Submit claims to: Humana Claims, PO Box 14601, Lexington, KY 40512-4601

www.humana.com CARD ISSUED: 03/27/2005

Member ID: 12345678-9Your Company NameGroup: 87654321RxBIN: 87654321RxPCN: 1234

Effective: 01/01/2006Issuer: 80840CopaymentsOFFICE VISIT: $10SPECIALIST: $30HOSPITAL EMERGENCY: $50

SAMPLECARDS, CHRISTOPHER S

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

(Front) (Back)

The number below the CMS logo (MedicareRx) corresponds to the member’s plan benefits. PDP plans begin with an “S” alpha character. Please refer to Appendix C for a listing of the PDP plans with the corresponding plan benefits. However, MA-PD plans begin with an “H” or “R” alpha character. Because of the wide variety of MA-PD plans, please refer to our Web site at www.humana.com for specific plan information.

Humana has entered into agreements with various chains (including Wal-Mart/Sam’s Club, CVS, Rite Aid and Brooks/Eckerd) for the purpose of driving health literacy through the distribution of educational materials about Medicare 2006 to Medicare beneficiaries. Therefore, a Medicare beneficiary may present a prescription card with the logo(s) of a pharmacy displayed on the bottom left corner of the card. However, the Medicare beneficiary may go to any pharmacy participating within the Humana national network; the beneficiary is not limited to the pharmacy displayed on the card.

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Humana Medicare Advantage Only PlansPlease 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.

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

Identification Cards

Card for patient with MA only plan (HMO)

(Front) (Back)

Card for patient with MA only plan (PPO)

(Front) (Back)

CMS H1234 001

HumanaChoicePPOA Medicare Health Plan

CUSTOMER SERVICE: 1-800-457-4708TDD/TTY Hearing or Speech Impaired: 1-800-833-3301

Physician and hospital authorization or notifi cation: 1-800-523-0023

Submit claims to: Humana Claims, PO Box 14601, Lexington, KY 40512-4601.PPOM Providers: PPOM Claims, P.O. Box 2720, Farmington Hills, MI 48333-2720.

Supplemental Benefi ts: DEN723 / VIS734 / HER820

www.humana.com CARD ISSUED: 03/27/2005

Member ID: 12345678-9 Effective: 01/01/2006CopaymentsOFFICE VISIT: $10SPECIALIST: $30HOSPITAL EMERGENCY: $50

SAMPLECARDS, CHRISTOPHER S

CMS H1234 001

CUSTOMER SERVICE: 1-800-457-4708TDD/TTY Hearing or Speech Impaired: 1-800-833-3301

Primary Physician/Center: XXX XXXXXXXXXXXTelephone: XXX XXX-XXXX

Physician and hospital authorization or notifi cation: 1-800-523-0023

Submit claims to: Humana Claims, PO Box 14601, Lexington, KY 40512-4601.

Supplemental Benefi ts: DEN723 / VIS734 / HER820

www.humana.com CARD ISSUED: 03/27/2005

Humana Gold Plus HMOA Medicare Health Plan

Member ID: 12345678-9 Effective: 01/01/2006CopaymentsOFFICE VISIT: $10SPECIALIST: $30HOSPITAL EMERGENCY: $50

SAMPLECARDS, CHRISTOPHER S

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Prior AuthorizationCertain 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 TherapyThe 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).

Claims Processing

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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.

Claims Processing

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Drug ExclusionsCMS 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.

RejectsCall 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 SplittingHumana 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 SuppliesHumana 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.

Claims Processing

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Coordination of BenefitsThere 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.

Claims Processing

Patient has Humana PDP or MA-PD only.

ACTION Bill the Humana Medicare prescription benefit. No coordination of benefitsis necessary.

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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).

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DESCRIPTION OF FIELD

FIELD ENTRY

EXPLANATION

Other Insurance Field/Other Coverage Code(NCPDP field 308-C8)

2 Other coverage exists, payment collected

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 (NCPDP field 431-DV)

$XX.XX Dollar amount paid by the primary carrier

Other Payer ID Qualifier(NCPDP field 339)

Qualifying ID of the primary insurance

Other Payer ID(NCPDP field 340)

Payer ID of the primary insurance

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Sce

nario

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.

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ReversalsBecause 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 ProcessingPlease 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 BenefitWith 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 DeterminationsMembers 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.

Claims Processing

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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 CoverageMembers 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 ManagementMedication 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:

Claims Processing

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Claims Processing1. 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 plan3. 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 RatesThere 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.

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Members of Humana’s Medicare Part D program will also receive a valuable new tool that can help you and them better manage their prescriptions. Starting in February 2006, Humana will begin sending SmartSummary Rx (see image below) to all Medicare Part D prescription drug plan members.

By compiling a record of the member’s prescription drugs, over-the-counter medicines and information about office samples all in one place, this monthly statement can help facilitate drug safety and continuity of care.

An Introduction to Humana’s

SmartSummary RxSM

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

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• Help members better understand the details of their prescription drug plan and feel more confident in the decisions they make regarding their health and health care spending.

• Give members more confidence in their interactions with you by providing them with a portable “Rx Manager” they can use to talk about their prescriptions and health care.

• Better prepare members to manage future health care spending with an easy-to-read statement that enables them to view all of their prescription drug spending in one place.

• Provide personalized messaging that will highlight potential savings opportunities members can take advantage of in the future.

SmartSummary RxSM

will:

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: SmartSummaryFeedbackProvider@humana.com.

Important Phone Numbersand Web Site Information

WEB SITE PHONE NUMBER

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

TDD: 1-877-833-44867 a.m. to 7 p.m.Monday through Friday

HUMANA MEMBER CUSTOMER SERVICE

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

HUMANA CLINICAL PHARMACY REVIEW (HCPR)

1-800-555-CLIN (1-800-555-2546)

HUMANA PHARMACY NETWORK CONTRACTING

Fax: (502) 580-2200

HUMANA PDP CUSTOMER SERVICE (CURRENT AND PROSPECTIVE MEMBERS)

1-800-281-6918

HUMANA MA-PD CUSTOMER SERVICE (CURRENT MEMBERS)

1-800-457-4708

HUMANA MA-PD CUSTOMER SERVICE (PROSPECTIVE MEMBERS)

1-800-833-2364

HUMANA ETHICS HELP LINE 1-877-5THEKEY (1-877-584-3539)

HUMANA HELP DESK (ARGUS, CLAIMS PROCESSOR)

1-800-865-8715

CENTERS FOR MEDICARE AND MEDICAID SERVICES www.medicare.gov

1-800-Medicare;(1-800-633-4227) (TTY 1-877-486-2048) 24 hours a days, 7 days a week

YOUR GUIDE TO MEDICARE PRESCRIPTION DRUG COVERAGE

This free booklet is available upon request by contacting 1-800-MEDICARE. It is CMS publication #11109.

SOCIAL SECURITY ADMINISTRATION

www.socialsecurity.govor www.ssa.org

1-800-772-1213 ; TTY: 1-800-325-07787 a.m. to 7 p.m. Monday through Friday

STATE HEALTH INSURANCE ASSISTANCE PROGRAM (SHIP)

Every state has a SHIP office to assist 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 PRESCRIPTION ASSISTANCE

www.pparx.org 1-888-4PPA-NOW (1-888-477-2669)

21

Q: What do I do if a Medicare beneficiary shows up in my pharmacy 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 do this, check with your pharmacy software vendor for the procedure. To perform an eligibility check, you will need this information from the patient:• First Name• Last Name• Date of Birth• Gender • ZIP Code• One of the following: • ID number from Medicare Part A card • ID number from Medicare Part B card • Last 4 digits of the Social Security Number

NDC Health will respond with the appropriate information for all payers that this beneficiary has (primary and secondary).• Insurance Level • “PRIMARY” for primary insurance • “ADDINS” for secondary insurance• BIN and Processor Control Number• Help Desk Phone Number• Cardholder ID• Group Number• Person Code Q: What happens if a customer shows up with a Humana card, but I get a reject saying that the customer is not covered?A: The pharmacy should call the Argus help desk. If the patient has not been loaded to Argus, Argus will forward the call to the Humana customer service desk.

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?A: Please provide the customer with the Humana Medicare Part D brochure. The individual may also go to www. Humana.com or call 1-800-845-1265, 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.

Q: Where can an enrollee go to learn more about the different plans that Humana has to offer and what is the best option?A: An enrollee can go to www. Humana.com or call 1-800-845-1265, 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.

Questions and Answers

WEB SITE PHONE NUMBER

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

TDD: 1-877-833-44867 a.m. to 7 p.m.Monday through Friday

HUMANA MEMBER CUSTOMER SERVICE

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

HUMANA CLINICAL PHARMACY REVIEW (HCPR)

1-800-555-CLIN (1-800-555-2546)

HUMANA PHARMACY NETWORK CONTRACTING

Fax: (502) 580-2200

HUMANA PDP CUSTOMER SERVICE (CURRENT AND PROSPECTIVE MEMBERS)

1-800-281-6918

HUMANA MA-PD CUSTOMER SERVICE (CURRENT MEMBERS)

1-800-457-4708

HUMANA MA-PD CUSTOMER SERVICE (PROSPECTIVE MEMBERS)

1-800-833-2364

HUMANA ETHICS HELP LINE 1-877-5THEKEY (1-877-584-3539)

HUMANA HELP DESK (ARGUS, CLAIMS PROCESSOR)

1-800-865-8715

CENTERS FOR MEDICARE AND MEDICAID SERVICES www.medicare.gov

1-800-Medicare;(1-800-633-4227) (TTY 1-877-486-2048) 24 hours a days, 7 days a week

YOUR GUIDE TO MEDICARE PRESCRIPTION DRUG COVERAGE

This free booklet is available upon request by contacting 1-800-MEDICARE. It is CMS publication #11109.

SOCIAL SECURITY ADMINISTRATION

www.socialsecurity.govor www.ssa.org

1-800-772-1213 ; TTY: 1-800-325-07787 a.m. to 7 p.m. Monday through Friday

STATE HEALTH INSURANCE ASSISTANCE PROGRAM (SHIP)

Every state has a SHIP office to assist 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 PRESCRIPTION ASSISTANCE

www.pparx.org 1-888-4PPA-NOW (1-888-477-2669)

22

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.

Questions and Answers

23

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 PDPP.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.

Questions and Answers

24

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.

DefinitionsThe 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).

Appendix A - Medicare Overview

25

• 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.

Appendix A - Medicare Overview

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

First, members pay a yearly deductible of $250. This means the member must spend $250 on their prescription drugs before the drug benefit starts.

The drug plan pays 75 percent of the total drug costs until the total drug costs for the year reach $2,250.

25%

MEMBER PAYS PLAN PAYS

75%

After that, the member pays 100 percent of the drug costs (from $2,250 to $5,100). In other words, the member pays the next $2,850.

$0

$2,250

$5,100

$250

95%

Nothing at this point.

Nothing at this point.

The drug plan pays 95 percent of the cost of the drugs after the member spends $3,600 in a calendar year.

Then, the member pays five percent of the drug costs (or a small copayment) for the rest of the calendar year.

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

How the basic coverage of the Medicare prescription drug plan works

5%*

26

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

Appendix B - Low Income Subsidy Chart

DeductibleCopayment

up to Out-of-Pocket Limit

Copayment Above Out-of-Pocket

Limit

Full Benefit Dual Eligibles (Institutionalized)

$0 Generic $0Brand $0

Generic $0Brand $0

Full Benefit Dual Eligibles at or below 100% of Federal Poverty Level (FPL)

$0 Generic $1Brand $3

Generic $0Brand $0

Full Benefit Dual Eligibles above 100% of FPL

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

$0

$0

Generic $2 Brand $5

Generic $2 Brand $5

Generic $0Brand $0

Generic $0Brand $0

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

Income from 135% to 150% FPL (w/assets that do not exceed $10K Indiv and $20K Couple)

$50

$50

15% Coinsurance

15% Coinsurance

Generic $2 Brand $5

Generic $2 Brand $5

27

Appendix C - Humana Plan Designs

S5552-002S5884-031S5884-032S5884-033S5884-034S5884-035S5884-036S5884-037S5884-038S5884-039S5884-040

S5884-041S5884-042S5884-043S5884-044S5884-045S5884-046S5884-047S5884-048S5884-049S5884-050S5884-051

S5884-052S5884-053S5884-054S5884-055S5884-056S5884-057S5884-058S5884-059S5884-060

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

S5552-001S5884-001S5884-002S5884-003S5884-004S5884-005S5884-006S5884-007S5884-008S5884-009S5884-010

S5884-011S5884-012S5884-013S5884-014S5884-015S5884-016S5884-017S5884-018S5884-019S5884-020S5884-021

S5884-022S5884-023S5884-024S5884-025S5884-026S5884-027S5884-028S5884-029S5884-030

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

S5552-003S5884-061S5884-062S5884-063S5884-064S5884-065S5884-066S5884-067S5884-068S5884-069S5884-070

S5884-071S5884-072S5884-073S5884-074S5884-075S5884-076S5884-077S5884-078S5884-079S5884-080S5884-081

S5884-082S5884-083S5884-084S5884-085S5884-086S5884-087S5884-088S5884-089S5884-090

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

28

You have the right to get a written explanation from your Medicare drug plan if:• Your doctor or pharmacist tells you that your Medicare drug plan will not cover a prescription drug in the amount or form prescribed by your doctor.• You are asked to pay a different cost-sharing amount than you think you are required to pay for a prescription drug.

The Medicare drug plan’s written explanation will give you the specific reasons why the prescription drug is not covered and will explain how to request an appeal if you disagree with the drug plan’s decision.

You also have the right to ask your Medicare drug plan for an exception if one of the two situations exists:

• You believe you need a drug that is not on your drug plan’s list of covered drugs. (The list of covered drugs is called a “formulary.”) • You believe you should get a drug you need at a lower cost-sharing amount.

What you need to do:• Contact your Medicare drug plan to ask for a written explanation about why a prescription is not covered or to ask for an exception if you believe you need a drug that is not on your drug plan’s formulary or believe you should get a drug you need at a lower cost-sharing amount.

• Refer to the benefits booklet you received from your Medicare drug plan or call 1-800-MEDICARE to learn how to contact your drug plan.• When you contact your Medicare drug plan, be ready to tell them:

1. Name the prescription drug(s) that you believe you need.

2. Give the name of the pharmacy or physician who told you that the prescription drug(s) is not covered.

3. State the date you were told that the prescription drug(s) is not covered.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB (Office of Management and Budget) control number. The valid OMB control number for this information collection is 0938-NEW. The time required to distribute this information collection once it has been completed is one minute per response, including the time to select the preprinted form and hand it to the enrollee. If you have any comments concerning the accuracy of the time estimates or suggestions for improving this form, please write to:

CMS7500 Security BoulevardAttn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850.

Appendix D - Medicare Prescription Drug Coverage and Your Rights

NOTES:

29

Appendix D - Medicare Prescription Drug Coverage and Your Rights

NOTES:

GH19208PR (12/9/2005) 12/05