UPDATE: Humana and Prime Therapeutics’ Response to Waivers from Strict Requirements for Independent Pharmacies Amid COVID-19 Crisis
As previously discussed in our post, “What Are the PBMs Doing Amid COVID-19 Crisis: Waivers from Strict Requirements May Exist for Independent Pharmacies,” many healthcare companies alike are taking further actions to ensure that patients have access to the critical healthcare services they need and to help diminish the unnecessary risks of exposure and contact to those outside of close family members or cohabitants in light of the COVID-19 outbreak.
Humana has joined the efforts of other PBMs and has announced that, during the COVID-19 outbreak, it will waive any “refill too soon” edits to accommodate for early fills of medications which are safe and clinically appropriate. Humana has also agreed to relax its terms with respect to signature log requirements and mail/delivery restrictions for claims with dates of services in March and April 2020. Specifically, Humana will waive any mail or home delivery restrictions for retail-only pharmacies to allow patients to receive medications via mail or home delivery. Additionally, if pharmacies are unable to obtain signatures indicating the receipt of medications, Humana will accept point-of-sale documentation evidencing the date and time that the prescription was sent out for delivery.
Furthermore, in order to address potential shortages of medications, if a generic drug is not available, utilizing a “DAW 8” will permit the brand version of the medication to be processed without subjecting the pharmacy to a reimbursement penalty.
With respect to pharmacy audits, Humana has asserted that it will not initiate new desktop and onsite audits and that it will suspend all desktop and onsite audits that are in progress until April 30, 2020 with the exception of audits requested by CMS or audits that are initiated due to fraud, waste, abuse concerns. A temporary suspension of desktop and onsite audits by Humana does not, however, suggest that claims processed during this suspension period are not exempt from a future audit.
In addition, Prime Therapeutics (“Prime”) has declared that, effective March 24, 2020, in light of the COVID-19 crisis, Prime is temporarily suspending daily and historical desktop claim audits with the exception of fraud, waste, abuse investigations and essential audits as may be required by federal or state law. Additionally, if a pharmacy is unable to capture a patient signature because of COVID-19 related reasons, Prime will accept documentation notating “COVID-19” on the prescription order, delivery records, or notation in the pharmacy’s software system with a date and time stamp. Lastly, with respect to mailing prescriptions, Prime has stated that pharmacies can mail prescriptions to patients so long as they are licensed in the states that they are mailing or delivering to.
How Frier Levitt Can Help
Frier Levitt is actively assisting pharmacies seeking waivers from State Boards of Pharmacy, PBMs and CMS. For more information on how to address these PBM practices, contact Frier Levitt to speak with an attorney.