Prescriptions
What information do you have to gather when collecting medication list?
Name and spelling of Rx
brand or generic
form & release type
dosage
quantity and frequency
packaging size
After going over the required benefits of the plan what do we offer to do for the member?
The full SOB
For every PCP, specialist, hospital, etc. what two pieces of information should we be confirming?
Address and Network Status
What is required when gathering members callback number?
Consent to call or text and "Consent can be revoked at any time. Standard messaging rates apply."
How long do you have to greet the caller to meet compliance?
10 seconds
If the member does not provide a drug list what should you advise?
"Mrs. Smith, I will be unable to confirm your medications are covered under plans formulary, do I have your consent to continue?"
What are the ancillary benefits agents are required to cover?
OTC
Transportation
SSBCI
HVP Program
OSB Benefits
For California HMO plans when searching for providers what must be reviewed?
IPA affiliation
What is the proper way to greet the caller?
Hello my name is (your name) I'm a licensed agent with Aetna Medicare and whom do I have the pleasure of speaking with today?
When collecting demographic information what are you required to confirm and obtain after the callers name?
Confirm callback number and obtain permission to contact through TPCA disclaimer and consent can be revoked at any time standard messaging rates apply, address and member ID
When going over the plan what information are you required to go over for each medication provided?
Name of Rx and dose
tier the drug falls under
covered under drug formulary or not
cost of medicaation
pharmacy
type of medication ex capsule or tablet
restrictions such as:
step therapy
Quantity limit
and prior authorizations
What information are you required to provide for dental, vision and hearing?
Everything in SOB including copays, benefits maximums and network.
If a provider is OON what clear guidance should we provide for PPO?
For PPO we cannot guarantee an OON provider will accept them as a patient.
What is required to be completed on an outbound call?
Identify as a licensed agent, inform the caller the call is recorded, obtained consent to continue with the recorded call and confirm two identifiers to comply with HIPAA.
In the application after all of the verbal attestations are gone over what must you obtain?
Consent to submit application for plan.
When presenting a PDP what plan information are you required to go over?
-Plan name and ID
-Plan Premium
-Drug deductible
-Network Status for pharmacy
-Coverage outside the US
-Tier Copays
- Agent is expected to review the drug
coverage phases
-Prescriptions copays
What are the required benefits that we have to go over with the member for MAPD?
-Plan name/type
-Plan ID
-Plan Premium
-Deductible
-PCP/Specialists copays (INN and OON)
-Inpatient hospital copay (INN and OON)
-Coverage outside the US
-Dental/vision/hearing
-Ancillary benefits
-Drug deductible (if applicable)
- drug coverage
- OTC
-Pharmacy INN and OON preferred or standard
-routine transportation
-ambulance
What clear guidance should we provide for HMO regarding network status?
If provider is OON for HMO the member would be responsible for the full cost of the visit.
What is your reason and commitment?
I will be happy to assist (state member's needs) in order to get started I will be asking some questions to identify your needs find a solution to those needs and get you protected today how does that sound?
What ID numbers must be stated during the application either by the member or the agent?
Medicare number
Medicaid number
and
Member ID number
What should you notify the member of if the pharmacy they provide is OON?
The member would be responsible for the full cost of their Rx.
What two things should you go over in the plan concerning the transportation benefit?
Routine transportation
Ground ambulance and air ambulance transportation.
If the member does not provide a list of providers what must you advise the member and obtain?
"Mrs. Smith, I will be unable to confirm your doctors are considered in the network, do I have your consent to continue?"
Name six needs assessment questions.
1. Plan name/Premium
2. hearing dental and vision
3. PCP and Specialists and how often do you see these providers
4. Hospital or DME (preferred providers)
5. Rx
6. Pharmacy
What must you complete before providing any specific plan information?
SOA (scope of appointment)