Pharmacy Basics
What program could members be eligible for to obtain additional financial assistance?
State Pharmaceutical Assistance Program (SPAP).
Members may be eligible for additional financial assistance through a State Pharmaceutical Assistance Program (SPAP). SPAPs are state-sponsored programs designed to assist low-income individuals with premium, deductible, and/or copayment subsidies to qualified Medicare members.
If a drug is no longer covered by insurance, how would the member be contacted?
Impacted members are notified by mail indicating why their drug is no longer covered and options to discuss with their doctor.
Vaccines are antibodies that help guard the body’s defenses against disease.
Members are limited to a set number of vacation overrides every rolling __ months.
Members are limited to a set number of vacation overrides every rolling 12 months.
Medicare Always Pays First!
Medicare plans are primary over Medicaid. If the member is covered by Medicare, it pays first.
Document pharmacy usage type calls in QuickStart+ under the following selections:
Classification: Rx
Intent: Pharmacy Finder
What type of calls would you receive if the member calls to ask to check their drug coverage and confirm their out-of-pocket expenses.
Verification of Benefit (VOB) calls are where the member asks to check their drug coverage and confirm their out-of-pocket expenses.
How many types of diabetes are there?
2 Types:
Type 1 and Type 2.
Please describe what a DNI code means.
Claims with status code DNI mean the medication is not covered under the member's plan and have at least one hard error.
True or False:
Would members contact Humana if they were quoted over the phone or amount charged at the pharmacy is incorrect?
True.
Members may contact Humana suggesting the price they were quoted over the phone or amount charged at the pharmacy is incorrect.
True or False:
Is pre-approval needed for compound drugs?
Preapproval is required on most compound drugs, and medications with restrictions or specialty uses.
What is a Drug Claim?
A "drug claim" occurs when members use their prescription drug coverage. For instance, a patient is treated by a doctor for an illness or injury. The doctor writes a prescription allowing them to obtain a medication. When the prescription drug is filled, the dispensing pharmacy enters the charges in their point of sale (POS) system to determine how much money is owed. This process is referred to as filing a claim.
Prescription drug benefit information is confirmed in what system?
RxConnect Pro
Prescription drug benefit information is confirmed in RxConnect Pro. The name, dosage, and frequency are entered in the Drug pricing section to verify if a drug is covered.
_______ are when a portion of the charge is applied to the Deductible, Initial Coverage, or Catastrophic stage.
Split claims are when a portion of the charge is applied to the Deductible, Initial Coverage, or Catastrophic stage.
When is an Appointment of Representation (AOR) form required?
There could be times when a member chooses to withdraw a prior authorization request for a Part D medication. An Appointment of Representation (AOR) form is required if another party (family member, prescriber, agent, etc.) submits or cancels a coverage determination request on the member's behalf. Humana dismisses the request if the requestor for instance, a spouse, does not have the proper AOR form on file.
RX Connect Pro and RX Nova are similar systems. How are they similar?
Both tools contain similar information. This is because RxNova feeds data directly to RxConnect Pro.
RxConnect Pro: provides basic benefit and claim information.
RxNova: contains additional benefit, claim, and authorization details.
When handling a live call, where is the guidelines launched?
Guidelines are launched directly from QuickStart+ when handling live calls. During training, they're accessed from the applicable Document Index in Mentor.
You receive a call from a member that has questions about Over The Counter (OTC) medications, what would your Classification and Intent be?
Capture OTC related calls in QuickStart+ as follows:
Classification: Rx
Intent: Over-the-Counter (OTC)
What system would be used for members to electronically submit a DMR claim form online?
Members can electronically submit a DMR claim form online through PromptPA.
Bob Customer (member) isn't happy with the outcome of his DMR decision and wants his next steps. You explain that he can complete and send in a Part D Determination Form. How can a member submit a Part D Determination Form?
1. Mail: Order paper form via the Order Management System (OMS) for the member to complete and mail back to Humana.
2. Verbally: Over the phone assisted by an advocate via CRM template.
3. Online: www.humana.com
If members wait too long to get their prescription, it could be cancelled. Generally, most pharmacies hold prescriptions for 7 – 14 days before cancelling the order.
How can members check the status of their prior authorization?
Members with an activated MyHumana account can check the status of a prior authorization via the MyHumana secured website under the Coverage section.
True or False:
Lost, stolen or damaged medications are not covered by Humana.
True.
As mentioned earlier, lost, stolen, or damaged medications are not covered by Humana. If a member attempts to get an early refill because they lost or can't use their medication, the cost comes out of their own pocket.
If an attempt is made to refill a RX before the available date, what error code will be present?
If a member attempts to fill a prescription before the next available refill date, the claim will deny in RxNova with hard error code 080-Refilled Too Soon. Members who are eligible can get an override at the pharmacy. Overrides force a claim to pay in RxNova for a drug that would normally otherwise deny.
Where are pharmacy dismissal letters are not visible in what 2 places?
Pharmacy dismissal letters are not visible in CRM or EMME. Obtain the letter code or ask them to read a portion of the letter to you to help identify these.