LIS
During what time of year are LIS TAN letters sent out to members?
Late October- early November
Which intent is used to file a CD request?
CAG intent
True or False, Premiums count toward moving the member into or out of any of the coverage stages.
False
Therapeutic shoes are covered under Part B or Part D?
Part D
What is the J code for a Vitamin B12 injection?
J3420
What color letter is sent out to members for "Facilitated enrollment notice letters"?
A Green Letter
What is the TAT for a written CD request once it is received?
TAT is 72 hours after the plan receives the request in the mail.
How can an advocate determine if a member is subject to a deductible and how much of the deductible has been met?
By launching the coverage stage intent
Alcohol swabs are covered under Part B or Part D?
Part D
which determination request form should be submitted for a request to exceed diabetic supply quantity limit?
MIOD
What color letter is sent out to members for " change in extra help copayment letters"?
A Orange letter
How long does a prescriber have to provide information for a (QL) quantity limit CD request?
14 days to provide information for the review
What does "ANDA" stand for, and is it related to Brand or Generic RX?
ANDA= Abbreviated New Drug Application. A drug approved through this path is considered a generic
What prescription drug coverage is billed to the medical benefits as a "j" code?
Part B prescription drug coverage
What the member pays and what the plan pays are incorporated into what?
Total Drug Spend
True or False, for LIS level 3, members will pay $2.00 for a generic prescription.
False, LIS level 3 has no copay for brand or generic
True or False, Once a determination for a CD is made, OptumRX will reach out to the member to advise them of the decision.
True- OptumRX will attempt to reach out to the member.
_________ is the copayments and coinsurance that members pay that they are not reimbursed for.
TrOOP- true out of pocket
True or False, Part B coverage will pay for all Antigens that are prepared by a doctor?
False, Medicare part B will help pay for SOME antigens if they are prepared by a doctor and administered by a properly instructed person, under doctor supervision.
True or False, all LIS levels are not subject to a deductible, even if the plan they have chosen has one.
False, LIS level 4 members have a reduced deductible amount when it is applicable to the plan they are enrolled in.
In the deductible stage for LIS 4 benefit level, a member will pay 100% of medication costs until________ deductible is met.
$104 deductible
True or False, If a CD request is submitted for an incorrect drug, you as the advocate will need to update the current CD request with the corrected information.
False, if a CD request is submitted for an incorrect drug, a NEW request will need to be submitted with the correct drug info.
What is it called when a member always pays the lower/lesser of the following three amounts- Copay/coinsurance/ total cost of medication/ total cost to an non-insured consumer?
"Lesser of" language
Which determination request form should be submitted for a Pharmacy rejected Part D medication?
Optum PAS form
In order for a member to have a CD dismissal vacated, they must show good cause and make the request within_________ of the dismissal.
6 months