Coverage Determination
Types of Coverage Determinations
Systems Used for A&G
Turnaround Times (TAT)
Scenarios
100
Coverage Determination
What is a request for a decision to be made by the plan or its delegated entity (I.E OptumRx), to satisfy or lift the requirements for specific coverage?
100
A request for a decision about whether to provide, pay or not pay for a medication because it’s not on the plan’s formulary.
What is a non-formulary drug?
100
Used to look up a medication or provide member with alternative options.
What is RxWeb?
100
Turnaround time for a standard coverage determination.
What is 72 Hours- after OptumRX receives the doctor’s statement?
100
A member calls customer service because they picked up a prescription- Zolpidem Tartrate 10mg. The member paid $7 for the medication. The member states that they cannot afford the medication at the copay.
What is offer alternatives, additional assistance, Tier Exception?
200
The coverage determination turnaround time drop down is located in this system.
What is MIIM?
200
A tier cost-sharing decision when the member thinks the cost of the drug is too high.
What is a tier exception?
200
Used to document the coverage determination.
What is MIIM?
200
Turnaround time for an expedited coverage determination.
What is 24 Hours after OptumRX receives the doctor’s statement?
200
A member called in with an effective date of 10/01/2014. The member’s information is loaded in our system. The member received his formulary and noticed that one of his medications- DESOXYN 5MG Tablets is not covered on the plan’s formulary.
What is Formulary Exception?
300
The tier levels that are eligible for a Tier exception.
What are Tiers 2,3, & 4?
300
A request for a decision about whether to provide or pay for a medication because the drug is excluded and the member believes it should be covered by the plan.
What is CMS excluded drug?
300
Verify if an authorization was submitted or is on file for a medication.
What is RxClaim & PAS?
300
How the member’s health will be put in jeopardy by waiting the standard turnaround.
What is when submitting an expedited request, the documentation that must be included?
300
A member calls in stating that they paid $268. 98 for doxycycline monohydrate 100 MG. After researching, you see that the member’s level of Part D coverage is: Coverage Gap.
What is offer alternatives and additional assistance?
400
When a member believes that a Part D plan has asked him or her to pay a different cost- sharing amount than the member believes he or she is required to pay for a prescription drug.
What is Cost Sharing Dispute?
400
A decision whether a member has, or has not, satisfied a prior authorization or other utilization management requirement.
What is Prior Authorizations or Utilization Management?
400
The form that CCP’s are REQUIRED to complete when submitting a CD.
What is Prior Authorization System?
400
A standard coverage determination will stay in pending status for this long waiting on the physician's statement.
What is a total of 10 days?
400
A member calls in stating that their medication- Zolpidem Tartrate 15MG is being rejected. After researching, you see that a PA was initiated but denied due to the provider not submitting the supporting documentation. The member states that they really need the medication.
What is offer alternatives and Appeal.
500
Information that must be documented on a CD.
What is Caller information Full name of medication Dosage Frequency Found in RX web as Alternative drugs Additional assistance Turn around time?
500
Non- Formulary is when the plan does not cover the medication and it is not on the formulary. CMS Excluded is when the medication is considered a Part D excluded drug. (The drug is not on Medicare’s approved medication list)
What is the difference between non-formulary and Medicare excluded drugs.
500
Offered to the member prior to offering to submit a tier exception.
What is Formulary Alternatives or Additional Assistance (LIS)?
500
A member calls in stating that they paid $95 for their medication- ADOXA 150MG Capsule. The member states that they cannot afford the medication. After researching, you see that a non-formulary exception for ADOXA 150MG Capsule was approved for the member.
What is offer formulary alternatives, LIS?
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