Federal Programs

Humana Rx Quality Network Information

Posted on June 20, 2016

The Tennessee Pharmacists Association (TPA) has received numerous calls from pharmacist members regarding a recent proposed contract which was sent to pharmacies regarding Humana’s Rx Quality Network.

The following information was provided by Humana to TPA to help clarify any questions regarding the network: CLICK HERE for a one-page summary of this network provided to TPA by Humana.

Per Humana: For plan year 2017, Humana Pharmacy Solutions is offering a new quality-based network that rewards pharmacies on performance and establishes their pharmacy as in-network/preferred for (Medicare) PDP/MAPD plans.For Medicare Advantage (MAPD) Plans:

Pharmacies that are in the Quality Rx Network will be “Preferred” pharmacies, and the Humana MAPD Member will pay standard cost share at the “Preferred”pharmacies.
Pharmacies that are not in the Quality Rx Network will be positioned as “Non-Preferred” pharmacies, and the Humana MAPD Member will pay more than standard cost share at these “Non-Preferred” pharmacies. Claims will not deny at the “Non-Preferred” pharmacy, but the MAPD Member will pay more for their medications.

For Medicare PDP Plans:

Pharmacies that are in the Quality Rx Network will be positioned as “In-Network”, and the Humana PDP Member will pay standard cost share at the “In-Network” pharmacy.
Pharmacies that are not in the Quality Rx Network will be positioned as “Out-Of-Network” for Humana PDP Plans. Claims will deny at “Out-Of-Network”pharmacies for Humana PDP Members.

The information above is being provided to TPA members in an attempt to clarify recent questions regarding this plan. TPA abides by a strict anti-trust cautionary policy. TPA cannot provide advice to pharmacies regarding their participation in any plan or contract. The information above is being provided to members for informational purposes only, and pharmacies are required to make individual business decisions regarding whether or not to sign contracts and participate in plans.