Access & Verify
Has the caller been HIPPA verified and authenticated.
What is the minimum number of letters that are required to search for a medication in drug coverage search?
3
There is no generic equivalent.
Please explain formulary vs non formulary authorizations.
Formulary are covered medications (TPA and ST), Non Formulary are medications that are not covered (FCR)
Who are the 2 groups that are able to start a Commercial Prior Authorization?
Dr office and Pharmacy
Thank you for calling. My name is _______, a Prior Authorization Representative. May I please have the patient's member ID?
What are the 4 pieces of information that I need to collect from the caller about the medication?
Medication name, strength, quantity, and days supply
If the medication requires a ST and a QPDE, which case will I create first?
Step Therapy
Please list off 3 types of PLAs.
QD, DD, EUX, MDQ, QPDE, QDU
What is the standard phone number for the prior authorization department?
800-753-2851
What are the 3 pieces of the eligibility triangle?
Member Info, Group Info, and Family Coverage
What is the rejection code that will appear in claim summary if a quantity limit is being exceeded?
76
If a plan covers 30/30 and 90/90, and the patient requires 60/30 but there is no phone number after quantity limit message, can you build a prior authorization?
No, this would have to have an administrative appeal through BCR
Day 91
What is the purpose of documentation?
It provides research for the next agent that helps the patient and serves as a record of the call.
What are the 8 pieces of patient info that we can use to verify an account?
Member ID, Name, DOB, Address, Zip Code, Phone, Case ID, Rx Number
When I performing a drug coverage search, and no medication appears, what should I ask my caller?`
Proper spelling, if the medication goes by another name
Other than drug coverage notes, where is another place that you can possibly see that the prior authorization is client managed?
What Prior Authorization requires that before building, we first must click on Preferred Products?
Who is the only team within Express Scripts that is able to overcome an 88-DUR Rejection?
What will appear under the patient's account number, that is now grayed out, if you are not authorized to access it?
Red wording saying what department you need to transfer the call to.
If I cannot find the medication being searched for in the patient's account, and my caller says the patient may have a 2nd account, where will I find that 2nd account?
Search, Alternate Account
In the determine which rule takes priority module, what case is at the very peak of the pyramid and must be built last?
Cost Exceeds Max (CUPs)
A patient can meet coverage criteria without ever having a prior authorization completed for one specific product type. What is this product?
Step Therapy
What does HIPAA stand for?
Health Insurance Portability and Accountability Act