MChoice
What's the Work Instruction for Maintenance Choice and what is the Reject Code related to Maintenance Choice Program?
Content ID : TSRC-PROD-062836
Compass - Handling Maintenance Choice Calls
Reject Code: 73
Mr. Anderson called to check the status of his order for lisinopril 10 Mg. Upon checking, the order status shows as: Shipped.
What would you advise Mr. Anderson?
Mr. Anderson, I see that your lisinopril 10 Mg. has been shipped and will be delivered to your shipping address and the estimated arrival of your order will be on...
You can also check the status of your order delivery at caremark.com.
The member asked you about what a Deductible is and how it works, what would you tell him / her?
Deductible is the amount of money that the member is required to pay before the pharmacy benefits go into effect. The member pays the full price for medication until the deductible is met. After the deductible is met, the member will pay either a flat-rate co-pay or percentage-rate coinsurance for their medications.
How would you assist a Provider if the claim shows Denied, with a Reject Code: 75?
Share your screen and locate the Work Instruction containing the necessary step/s.
Compass - Prior Authorization (PA), Exceptions, Appeals Guide
Compass – Initiating an ePA Request (055814)
Step # 3: Warm Transfer to PA Team...
Mr. Smith asked if he is covered for the medication, Zepbound. Upon running a Test Claim, there is a Reject Code: 75.
What would you advise Mr. Smith. Provide the steps and Turnaround Time.
Mr. Smith, I see that the medication Zepbound needs Prior Authorization. I can send in an electronic Prior Authorization Form to your doctor. This will take up to 1 business day.
Your need to call your doctor so that he / she can completely fill-out the form and send it back to us. After full clinical information is received from the prescriber, it would take up to 3 business days for us to make a determination to cover the medication.
What is Maintenance Choice Incentivized and how does it differ from Maintenance Choice Mandatory?
Maintenance Choice Mandatory: The Member can only get their medication at MChoice participating Retail Pharmacies for a 90-day supply.
Maintenance Choice Incentivized: The member can still get the medication for a 30-day supply, however, every time they do, it becomes more expensive.
Ms. Brown called to check the status of her order for metformin 20 Mg. Upon checking, the order status shows as: Pending Carrier Pickup.
What would you advise Ms. Brown?
Ms. Brown, your metformin 20 Mg. has been shipped and is awaiting pickup by the carrier. Tracking details will be available once your order has been collected.
The member asked what a Maximum Allowable Benefit is and how it works, what would you tell him / her?
The maximum amount that will be covered, during a specified time frame, under a member's plan design. The total dollar amount a client or plan sponsor will spend on prescriptions. Once the MAB has been reached, the member must pay all prescription costs. What the member will pay after MAB depends on their plan set up.
A claim rejected with Reject Code 70: Drug/NDC Not Covered.
What are your next steps?
1. Check the denial reason for instructions / notes.
2. Check if there are available alternatives that the member can discuss with his / her prescriber and read the required disclaimer.
3. Inform the member that his /her prescriber may send a Formulary Exception or Appeal.
4. Offer savings programs / site where the member may get a manufacturer's coupon such as www.GoodRx if they choose to pay OOP while waiting for appeal results.
A claim rejected with Reject Code 76: Plan Limitations Exceeded.
What should you ask the member and what guidance do you give?
Ask the member: “Could you confirm the quantity and day supply on the claim?”
If the member needs more medication, advise him / her to contact the prescriber to request an additional day supply through a Prior Authorization.
The Member objects to the Maintenance Choice program rules. How will you assist?
Advise the member of the benefits of Maintenance Choice.
Choose where you fill: Choose where to fill maintenance prescriptions by a select participating pharmacy. They can find one via the Pharmacy Locator Tool on Caremark.com.
Save Money: In most cases, 90-days’ supplies offer cost savings over filling 30-days’ supplies at a time. Compare pricing via Test Claims to illustrate savings.
Save Time: No more monthly pharmacy trips. Most retail pharmacies offer home delivery, and with mail order, your medicine is delivered right to you. That means fewer trips to the pharmacy and the gas pump.
What is the Work Instruction to resolve order conflicts for: FUTURE FILL, PAYMENT ISSUE, ADDRESS VERIFICATION?
Content ID : TSRC-PROD-056291
Compass - Manage Diverts / Conflicts (Release Order)
Mr. Johnson, one of our members asked why his plan costs much more than what he normally spends last year.
What are your steps and how would you assist Mr. Johnson?
Advise the member that the price of the medication varies depending on the approved Plan Design and it may differ and change year after year.
1. Check the CIF, including the member's Plan Design.
2. In Compass, check the benefits link under the Member Snapshot.
3. Check the claim for the medication in question including the Copay / Deductible.
4. Check the Accumulations and compare it with the previous year.
A member says they received a denial letter for a PA that was submitted and wants help understanding it.
What are your steps and recommendations?
1. Open the Member Snapshot Landing Page, check the letter under the Communications link.
2. Review the denial reason and explain it to the member.
3. Discuss possible alternatives they may talk about with their prescriber.
4. Advise that the prescriber can request an Appeal for the same medication or submit a RX / PA for a different medication.
Where can you see who handles the Appeals and what is the Turnaround Time for the different kinds of Appeals?
Check the CIF, under the Appeals Tab.
Non-urgent Appeals are normally processed within 30 calendar days from date received.
Urgent Appeals are processed within 72 hours.
External Reviews turnaround time is 45 calendar days once the Independent Review Organization receives the request.
The member already Opted Out of the Maintenance Choice Program. Can he / she still cancel the request?
Yes. In the PA / Override History, select the opted out medication. Click the caret symbol on the row-level action button and select the option to Cancel the MChoice Opt Out.
If Option is not available, ask assistance from the Senior Team.
What is the Work Instruction when encountering the status: NOT AVAILABLE / NOT IN STOCK?
Content ID : TSRC-PROD-065451
Compass – Member Unable to Locate Medication at Mail Order or Retail (Back Order, Shortage, Not in Stock - NIS)
Allow time to pull up CIF: X3175
Member: Mr. Hui
Member Verbatim: How much is my coverage for Weight Loss Medication? If I pay for this medication, will it go towards my OOP?
What would you advise and recommend Mr. Hui?
Mr. Hui, for Weight Loss medications, this is processed at the contracted rate, where you are 100% responsible for the full cost of the drug.
Upon further checking with your current plan, the copay will NOT go towards your Out of Pocket and even after OOP has been met; you are still responsible for 100% copay.
However, I can recommend options for you to save on the cost of medications. You may go to www.goodrx.com...
If the rejected claim qualifies for an Urgent Appeal, what are your steps and what does the prescriber need to submit, including the turnaround time?
Advise the member that the prescriber needs to Fax the Letter of Medical Necessity to 1-866-443-1172. Have it marked as "Urgent". Turnaround time: 72 hours.
How can the prescriber send a Prior Authorization? And how are you going to tell it to the member in a positive way?
Suggested Script: In order for us to process the appeal much faster and more accurate, your prescriber may either call our Prior Authorizations team at: 1-800-294-5979, or they can also submit a Prior Authorization request at CoverMyMeds.
The member is expressing concerns about the cost of moving their prescriptions from Maintenance Choice Voluntary.
Member Verbatim: I don’t like paying for a three-month supply four times a year versus paying each month for a one-month supply.
How would you respond?
When you fill your long-term medicines every month at your current retail pharmacy, you may be paying more than you need!
You can save gas when you avoid monthly trips to the pharmacy. I can perform a price estimate to show you how much you’ll save then you can decide which choice would work out better for you?
We also accept all major credit cards and electronic checks.
When receiving Prescriber-Related delays/errors, such as: DELAYED PRESCRIBER RESPONSE, how will you assist the member?
Run a Test Claim.
If Accepted (Offer FastStart/New Rx Request):
Content ID : TSRC-PROD-054208
Compass - Obtaining a New Prescription (Rx) for the Member (New Rx Request)
If Denied: May submit an Appeal
Content ID : TSRC-PROD-063978
Compass - Prior Authorization (PA), Exceptions, Appeals Guide
A member has been stable for years on Synthroid 100 mcg and insists the brand is the only product that keeps their thyroid levels stable. Their new prescription from the endocrinologist is written “DAW – Brand Medically Necessary”.
At the pharmacy, the claim is submitted with DAW 1 (Prescriber requested brand). The claim rejects:
The member is upset and says:
“My doctor requires Synthroid. I have lab fluctuations with generics. Why won’t Caremark cover it? Can you override this? I am not switching.”
How would you assist the member and what are your recommendations?
I hear you. Your plan requires generics by default, which is why Synthroid rejected. The good news is we can request an exception if your doctor provides medical reasons—like prior instability on generic.
“Here’s what I recommend:
I’m not able to override the plan’s mandatory generic rule. However, I can start the appropriate exception process right now by sending the PA details to your doctor’s office. That’s the correct path to request coverage for Synthroid.
I'll send now the ePA form to your prescriber. Would you like me to provide you with the phone number of our PA Team, for your prescriber to call?
Member Verbatim: I went to pick up my medication at a local pharmacy and received a denial. It says, “prior authorization expired.” What does that mean?
Prior authorizations for medications are often only valid for a specific period, for 6 months up to 3 years. After that, a new prior authorization is required.
The member is requesting for a Clinical Exception for Gabapentin gel.
What is the Clinical Exception that can be applied to this request and if approved, how will the cost be applied?
* Formulary Exception: It is when a drug is normally not covered on the plan (plan exclusion). Once approved, medication will be added to the highest “non-specialty” tier for the member’s plan.
* Sample Reject Code: 70 (Drug / NDC is not covered)