SP, B&B, ST
Responsible for dispensing medications for complex conditions.
What is a specialty pharmacy?
This person initiates the prior authorization.
Who is the provider?
This is the status when medication will not be covered by the insurance.
What is denied?
Also known as fail first policy, what program requires patients to try a lower cost prescription drug that treats a given condition before using a similar-acting, but more expensive drug.
What is step therapy?
Type of approval may need to be provided by a payor before acquiring a medication or treatment.
What is a prior authorization?
This pushback is required if the agent provides a PA that is Future dated, Expired, Denied or Pending.
What is "Is there an active one?"
The process for physicians to acquire medications that can be administered in the office.
What is buy & bill?
If an agent offers to start the prior authorization process, this is the only appropriate response.
What is "By the way, I am not initiating a prior auth; just inquiring about the submission process or status, if applicable"?
If the agent says PA is approved for 300 units, what do we input?
What is "5 treatments"
If buy and bill is not available, this is where patients can get their medication.
What is specialty pharmacy?
When asking how to obtain prior authorization, these are the four pieces of information we need to attempt to collect.
What is the department name, phone number, website and fax number?
The PA is cancelled and there is no active PA on file. This is the proper way to enter that data on the platform.
What is "Not on file?"
What is "How does the patient get their specialty medication?"
This pushback is required when we are told that a PA is required and member's plan is a secondary plan.
What is "Is that true when the plan we're calling on is secondary?
If the agent cannot see the diagnosis code on the approved prior authorization what do we input?
What is Approved?