PN 101
The name for agents supporting members in the Pharmacy Navigator program
What are Benefit and Clinical Advocates?
Primary data source used to identify PN opportunities
Opportunity triggered if the members medication is changing tiers and will be more expensive.
What is a drug tier change?
The process that is kicked off if more clinical information is required for the member to fill their medication.
What is the prior authorization process?
These opportunities allow members to reduce out-of-pocket costs by making optional changes to their medication or how they receive it.
What are Member Savings Opportunities?
The line of business PN will support at go live.
What is Commercial?
The system advocates can use to enter tickets for expedited work with partner teams
A formulary change can cause this financial consequence for members who want to stay on their current therapy.
What is an increase in out-of-pocket cost?
The type of denial that occurs if clinical information is reviewed but drug is deemed inappropriate for the member.
What is a PA denial, general?
This type of savings opportunity involves switching to a medication that works the same but costs less.
What is a cost-effective alternative medication?
The primary way that PN will interact with members at go live.
What are outbound calls?
Clinical resources supporting the PN program
What are RNs and registered pharmacists?
When a medication is removed from this list, members may face higher costs or need to switch therapies.
What is the formulary?
The type of denial that occurs if not enough clinical information was received for review.
What is a PA admin denial?
A member currently fills prescriptions at retail but could save money by switching to this channel.
What is mail order?
The point in the member journey that PN focuses their outreach
What are potentially abrasive moments in the member journey?
The dialer type that allows the advocate to initiate the call.
What is the preview dialer?
This type of change can occur when a member’s preferred pharmacy is no longer included in their plan’s approved options
What is a network change?
"PA required" means this in the context of the PN program.
What is a prior authorization is on the members medication?
A member can lower costs by changing from a 30-day supply to this longer supply schedule.
What is a 90-day supply?
The five clients PN will have for 1/1/2026
What are Texas Health Resources, Halliburton, St. Jude, Warner Bros, WorkDay?
The dialer type that will be used for most member calls
What is the progressive dialer?
Specific timing when members should receive outreach about a formulary or network change.
What is 2 weeks before their refill date?
The term that PN uses to distinguish opportunities of higher clinical importance.
What is "urgent"?
This program helps members on specialty medications by offering copay card assistance.
What is Prudent Rx?