Terminology
Define PAP
The Patient Assistance Program is a program in which uninsured and underinsured patients can qualify for the prescribed drug for up to a year.
What does MM stand for, and what does PBM stand for?
Major Medical and Pharmacy Benefit Manager.
Medicare Patients must provide what before they can be evaluated for PAP?
$600 spend down.
What do we need to confirm on an inbound call from the Pt.
Caller Name
DOB
ZIP Code
Missing an AE will result in what?
A Cappa which will put the agent on an automatic PIP.
Define AE
An adverse event is any untoward medical occurrence in a patient, clinical investigation subject or consumer that is temporally associated with the use of a GSK/ViiV product, whether or not related to a product.
What is the difference between Medicare and Medicaid
Medicare= covers people age 65 and older, as well as those with certain chronic conditions or disabilities.
Medicaid= Medicaid is typically available to those with a lower income.
What can we take as POI for PAP?
Most recent signed Federal Tax Return
Most recent W-2
Most recent bank account statement(s) showing income deposits (in lieu of pay stubs) for the most recent 30 days.
Applicants whose income has decreased from the prior year or previously submitted can submit a letter indicating the income decrease along with supporting proof of income for the most recent 30 days.
If the documents listed above are not applicable, patient will confirm household size and income by completing a verbal attestation or providing a written declaration.
What is the outbound call opening script?
Hello, this is [CM first name] calling on a recorded line regarding an enrollment we received from Dr. [Full Name]. Is this a good time to talk? Can you please confirm your Name, DOB, and Zip Code? Before we get started, I do want to let you know that this call may be monitored, recorded, and shared with ViiV Healthcare and its agents for quality and training purposes. Do I have your permission to record the call?
What are the steps to properly perform an ECHO for a shipping address?
Asks the caller for the complete mailing/shipping address.
Asks if there is an apartment, lot, unit, or suite number if not already provided.
Immediately repeats the address provided by the caller in its entirety.
Allows for confirmation of the address from the caller and makes any needed corrections.
Define Specialty Medication
Specialty drugs are high-cost prescription medications used to treat complex, chronic conditions like cancer, rheumatoid arthritis, and multiple sclerosis.
Explain the difference between AOB and Buy and Bill.
AOB= getting medications from the SP and the SP billing the MM insurance.
Buy and Bill= Doctor purchasing medications to give patients and billing the MM directly.
How many days before PAP expiration do we make an attempt to obtain a new EF. How many times do we do this and how often do we?
60 days before, once a week and make 3 attempts.
What type of MI is not required to complete BI?
Prescriber Signature
True or False: A call that has multiple cases discussed in it must be attached to every case discussed.
True
Define Drug Class Exclusion
A Drug Class Exclusion is when an insurance company won't cover any medication for a certain disease state.
If someone has a Marketplace plan, can they get a copay card?
It depends if the Marketplace plan is backed by Medicaid or not. If it is then no if not, then yes.
What part of Ryan White can a pt. not have to get on PAP?
Part B (ADAP)
How many lifetime planed missed doses can be distributed for Apretude?
4
How do you confirm someone's authorization to receive PHI on an outbound call?
At the start of an outbound call, recipients and the organization they represent (if applicable) should be identified either via IVR or direct statement. If this did not happen, agent clarified the identity of who they were speaking to and their organization.
Define Alternate Site
An alternate site is a site that is used to give patients injections when the prescribing physician does not want to give the injection in house. Injections can be sent to these sites if they are listed on the Ef or we can help HCP and Pt find them using the alternate site locator.
On an SOB the MM states that the Rx is not covered, and they have a drug class exclusion and the PBM states that the drug is not covered but a FE can be submitted. What are the next steps for this Pt?
The HCP would need to submit the FE. If denied, we would then need to confirm that the PBM also has a drug class exclusion then the Pt. can be evaluated for PAP.
A pt. on PAP has started a new job and has obtained INS. What should you do next?
Ask for the PAP task to reopened to deny the PAP, mark that the Pt. has commercial INS to create the denial letter. Send the letter to the HCP and Pt. and email to SPL to notify Walgreens that PAP has been discontinued.
All program calls are to be documented in Lynk either in a case or in a GI. What is the one exception to this rule?
When an FRM is calling in for a non-patient related item.
What must you do before you add a new Pt. representative to a Pt. profile?
When authorizing a new patient representative, agent ensured the patient themselves was fully verified, that they understood the context of the conversation, and that the patient fully identified the person to be added to their profile.