Coverage Determinations pt.1
Coverage Determinations pt.2
True or False
Scenarios
BONUS
100
How many prescription tier levels are available to members? *Bonus* Receive 100 extra points if you can name each tier level
There are Five tier levels, Tier 1- Preferred Generic, Tier 2- Non-Preferred Generic, Tier 3- Preferred Brand, Tier 4- Non-Preferred Brand, Tier 5- Speciality Tier
100
When submitting a coverage determination what is the name of the form that is neccesary to complete the Coverage determination and on what site can it be found on? *hint* it provides CCP with a case ID.
PA initation form found on RXweb.
100
You can submitt a coverage determination if a member is in the coverage gap.
False, you can refer the member to the Prescribing doctor for alternatives and offer additional assistance programs such as myAdvocate
100
A member calls customer service upset because they picked up a prescription that is a tier 3 states they do not want to pay a tier 3 copay. Classify this call and provide a resolution.
Although the member is upset this call is considered a coverage determination.
100
What is the application in Citrix that a CCP uses to check for a prior authorization?
RXclaim
200
What is the standard information required for coverage determination documentation?
Caller information Full name and dosage of medication requested Frequency/ Quantity of drug The medication is found in RX web as Alternative drugs and additional assistance provided Turn around time
200
What is the turn around time for a standard coverage determination?
72 hours after OptumRX receives the doctor's statement.
200
With a standard coverage determination, a case will be pending for a physicians statment up to 7 days total.
False: It will be pending for up to 10 days total.
200
Jane the member is upset because she went to the pharmacy and stated it took 2 hours to receive her medication. The member also states that the 2 hour wait was frustrating because she had already driven 14 miles to the pharmacy. Classify this call and provide a resolution.
This call is considered a verbal grievance. Some of the resolutions that can be offered are: Offer to find a new pharmacy, offer to send pharmacy directory, provide member with aarpmedicareplans.com website to locate providers.
200
When a member is prescribed drug Y but drug Y requires a step therapy the member must...
The member must try generic drug X before brand drug Y can be rendered to the member.
300
If a member thinks that the current cost-sharing tier is too high, what is an option that you can provide the member aside from a tier exception?
Refer member to Prescriber (Physician) about formulary alternatives or Offer member additional assistance programs (myAdvocate/LIS)
300
Can a tier exception be submitted after a formulary exception?
No
300
It is acceptable to exit a member account on RXclaim without leaving call tracking notes if the call was disconnected. *BONUS* What job aid in mysme can a CCP use to learn how to submitt notes?
False. It is required that everytime a member account is opened a CCP must leave a note. *BONUS* RxClaim - Adding Call Tracking Notes 07292011 original SVC
300
ohn is a new member to the plan and his plan has an effective date of 10/01/2014. John received his formulary and noticed that one of his medications are listed as a non-formulary. Today is 09/25/2014, what would this call be classified as and how can you assist the member?
This call would be considered a coverage determination only if the member is already active in Rxclaim.
300
What are the different types of Coverage Determinations
Prior Authorizations or Utilization Management Review, Formulary Exceptions, Tier exceptions, Cost-Share.
M
e
n
u