Pharmacy
This program helps patients find cost-effective alternatives to their current medications, including generic drugs and biosimilars.
What is the Optum Rx formulary or drug list?
This is the condition in which the blood vessels that supply blood to the heart muscle become narrowed and blocked.
What is Coronary Artery Disease (CAD)?
This is the first rule of COB, determining which health insurance plan is primary when two plans are involved.
What is the "Birthday Rule"?
This is the primary reason why a person might undergo a total knee replacement (TKR).
What is severe osteoarthritis or joint degeneration?
When a mbr calls in with an issue, this is the first step in de-escalating the situation, aimed at establishing rapport and understanding.
What is active listening?
This is the typical delivery time for most prescriptions ordered through Optum's mail order pharmacy.
What is 7-10 business days.
The buildup of this fatty substance inside the coronary arteries is a major cause of coronary artery disease.
What is plaque (atherosclerosis)?
If a dependent child has coverage under both parents' plans, the plan of this parent is typically considered primary.
What is the plan of the parent whose birthday falls first in the calendar year?
This part of the knee is most commonly affected by arthritis and is most commonly replaced during TKR?
What are the femur, tibia, and patella?
This is a key technique used in de-escalation, where the representative speaks in a calm and reassuring tone to prevent further conflict.
What is maintaining a calm and composed voice?
With Optum Rx's mail order pharmacy, patients can usually get a 90 day supply of these types of medications.
What are maintenance medications?
When the heart's blood supply is significantly reduced or blocked, this potentially fatal event can occur.
What is Myocardial Infarction/Heart attack?
According to COB rules, if a person has multiple insurance plans, the primary plan is determined by this condition.
What is the employee's or subscriber's employment status?
A total knee replacement typically requires this length of post-surgical rehabilitation to regain full mobility.
What is several weeks to months of PT?
If a mbr is angry, this phrase is important to use to let them know their concern is valid, while helping to guide the conversation towards a solution.
What is "Let me help you with that?"
Lower-cost alternative medications that need to be tried prior to filling a medication prescription.
What is Step Therapy?
This common symptom of CAD occurs when the heart muscle doesn't get enough oxygen-rich blood, often felt as chest pain or pressure.
What is angina?
Under COB rules, when one plan pays a portion of the claim and the other pays the remaining amount, this is called this process.
What is "dual coverage" or "Coordination"?
This is one of the most common complications following total knee replacement surgery, where the patient's mobility is limited.
What is deep vein thrombosis (DVT)?
This de-escalation technique involves askingn open-ended questions that allow the mbr to explain their situation in more detail.
What is asking clarifying questions?
Before an expensive or specialty medication is covered by Optum Rx, this process ensures that the medication is medically necessary.
What is prior authorization?
This medical procedure may be performed to open up blocked coronary arteries, often involving a small balloon.
What is angioplasty (with or without stent placement)?
If one health plan is secondary, it will pay benefits only after the primary plan has done this.
What is "paid or processed the claim"?
This type of material is often used in the construction of the prosthetic knee joint, ensuring durability and minimizing wear over time.
What is titanium, cobalt-cromium, or polyethylene?
When a mbr becomes increasingly upset, it is helpful to offer this to ensure they feel heard, respected, and valued.
What is an apology or acknowledgement of the issue?