Pharmacy
A list of generic and brand name prescription drugs covered by a health plan.
What is a Formulary or Prescription drug list (PDL)
Required details for submitting and updating coordination of benefits are found in this SPA.
What is Eligibility advocacy
This tab is utilized in ISET to determine the plan Funding Arrangements.
What is Eligibility tab-Plan Details section
This is a tax-advantaged account created for or by individuals covered under high-deductible health plans (HDHPs) to save for qualified medical expenses. Contributions are made into the account by the individual or their employer and are limited to a maximum amount each year.
What is an HSA account?
The amount you pay for covered health care services before your insurance plan starts to pay.
What is a dedcutible?
To view deductible and out of pocket accumulations for pharmacy claims we would look in this tab.
What is the RX/DED/OOP/Max Accum tab in ISET.
View this SPA for Call Redirection, Call Avoidance and Courtesy Skills Hold/Delay/Disconnect processes.
What is Building Trust Through Advocacy?
This tab and system allows us to send correspondence to members from ISET.
What is Communications Tab> EZCOMM
A tax advantaged account that lets employees use pre tax funds to pay for eligible dependent care services, such as childcare, or adult daycare while they work, look for work, or attend school.
What is a Dependent Care FSA
The OOP maximum is the maximum amount of expenses that are to be paid by the member before the plan pays at 100% for all eligible expenses.
(TRUE / FALSE-
We can find information about the " Free Meter Program" in this section of ISET.
What is the Pharmacy Tab > Rx Benefits> Programs section
This SPA contains information related to coverage determination guidelines, breast pumps and durable medical equipment.
What is Benefits and Coverage Advocacy
To view an appeal we would look in these 2 places?
What is Escalation Tracking system or appeals icon at the top of ISET
This is an employer-funded spending account that reimburses employees for qualified medical expenses and, in some cases, insurance premiums.
What is an HRA?
This is an out of network reimbursement policy or program used to determine out of network rates to apply to out of network claims.
What is ENRP/MNRP?
A program that keeps pharmacy cost down by requiring members use other alternative medications in their formulary when available for the same condition.
What is Step Therapy?
A member called in to request a Michigan Coverage Letter. Name the spa the steps are located in.
What is the Claims Advocacy
To initiate a vacation override we would check this tab
What is the Pharmacy tab >Available Overrides Tab?
You establish this account through your employer. With this account you contribute via payroll deductions, your employer can also contribute. This money can only be used to pay for certain out-of-pocket health care costs.
What is an FSA ?
a period during which one may freely enroll in or change one's selection of a health insurance plan or other benefit program.
What is Open Enrollment?
Pharmacy Tab> RX Benefits> Compounds
This SPA provides information related to marketing campaigns, promotions and how to offer, enter and engage with members regarding program referrals.
What is the Proactive Member advocacy SPA?
when member is requesting a out of pocket maximum/ lifetime/accumulator review we would route to UNET GEN Q (True or False)
False: We warm transfer to tier 2
Claim filing limit is located on which screen in CAMS
What is The Spending Account tab in CAMS
Reference CAMS interactive job aid
This is an event that triggers a special enrollment period for an individual or family to purchase health insurance outside of the regular annual open enrollment period.
What is a qualifying life event?