Copay/Coverage Stage
What is the deductible amount for 2023
$505.00
What is the name of the PBM we will use in 2024?
Express/ ESI
Who would edit the PA backdate for a caller?
2.0 Inbound team
What plans are housed in Trucare Cloud?
New Mexico.
Can agents extend overrides?
Yes. Retail 3 days and MO 5 days.
What copay stage does the tier exception apply in?
Initial coverage stage
What application is used to check eligibility?
UMV
Where do you initiate an oral Appeal for IL MMP plans?
Online web page/ Blast
Submit a paper claim to CVS Caremark.
Where would you find the processing information for the pharmacy?
In the compendium
What override reason code should be used for diabetic supplies?
"MB"
What application will we use to replace Nice Engage in 2024?
Calabrio
Can agents complete a onetime override for members that were recently released from Hospice?
Yes.
Can an agent or supervisor place overrides for a RDUR restriction?
No. RDUR restrictions require a PA even if the medication is formulary.
If an agent places an O/R and the O/R is still not paying what should be the agent next step?
Retrace steps, check the NDC number is correct. Then refer back to the MPS override guide and make sure all edits were placed correctly.
What benefit stage does BD Pen Needles pay under?
Part D
How can you update OHI removal?
ADS
If a member needs medication and the PA is in effectuation status. What should the agent do?
Place a onetime override.
What does PAP stand for?
Patient Assistance Program
Where is the list of preferred diabetic supplies?
In the MRD under Part B coverage.
What is a cusp claim.
A claim that pays in two different phases.
What application can you use to locate AOR information?
Omni
When assistance is needed what's the first step an agent should take?
Use resources/ troubleshoot
If a provider is upset about a denied prior authorization and wants to speak with someone else. How should the agent handle this call?
Submit a Peer to Peer through service now providing details including two good callback times include PST or EST.
What is the address for paper claims?
Allwell Attn: Pharmacy Claims
P.O. Box 989000
West Sacramento, CA 95798