Override Request
What's something to consider before entering an override?
Read Trigger Window, KIP and Knowledge Information Management (KIM) for Client specific Information
1199 SEIU Benefit Fund Rules are..
•Zero Retail Fill Policy
•Do NOT load retail overrides or enter an RSO Prior Authorization override for patients.
•Encourage the patient to transfer Rx’s to Accredo.
•If the patient misses a dose because the prescription has NOT shipped yet, ask the patient if he or she has any questions or concerns about missing a dose and would like to speak with a pharmacist.
How do we make sure we get a conversion?
Make sure to Disposition it as DF/PT
4W Means..
PT enrolled in RSO (Retail Strategy Optimization) program and required to use Accredo. 4W rejection code received when another pharmacy tries to run a claim.
What's the difference between a RRA and RSO
Retail Strategy Optimization and Retail Refill Allowance
What is the criteria that must be met prior to an override being placed on a account.
Client Must Allow Override, RPH approval Required.
Do we provide Overrides for Premera BCBS?
No we do not, as they handle their Own Overrides.
If a PT has a VA (Veterans Affairs) or Retail Benefit Plan Do we call?
No we'd close the task.
Reject 40 Means
“Pharmacy Not Covered” simply means that the prescription cannot be filled at the pharmacy running the claim.
What does OOPP Stand For?
Out of Pocket Protection Plan
Can we enter Fertility Override Request?
No We'd complete the Override Request Template and Submit it to the E-Mail in question.
Would we convert a Gamastan Patient?
No we'd automatically provide a 1 Year override.
How do you properly disposition the database when a patient gives permission?
Disposition it as DF and Notate in ESD and Database.
Rejection 78 is
Cost Exceed Maximum.
Where would you go it find Information about specific clients?
KIM and KIP
What do we need to complete an override in the PA Screen?
GCN, NPI and Proper Notation from RPH.
For BCBS of Kansas City what Happens on 07/01/2020
Specialty Drugs MUST be Filled through Accredo.
What Information needs to be Filled out every time in Database?
Doctors Information.
Rejection 73 iS
RRA, PT has Exceed the max allowed at a Retail Pharmacy.
What's the ACT #
800-903-8224
When do we Submit a Manual Override?
We submit a manual override only for
73 Rejections
OR
Retail Penalty Application
Would we enter any Overrides for an Anthem Patient?
No, we are no longer the PBM for Anthem.
Rejection 75 IS
Prior Authorization Required.
Can A Pharmacy Rep or RPH from an outside Pharmacy Request an Override on behalf of the PT?
No only an authorized rep or the PT themselves can request one. Under Certain Situations.