SPRx Navigation
How would you locate dispense maintenance screen?
click rx number
If the Pt is experiencing possible side effects of the medication who will you transfer the call too ?
transfer to RPH pharmacist for patient counseling
Call comes in fully Authenticated by the Patient through CTI pop. Do we need to ask the patient for Name, DOB and Zip code before proceeding with the call?
No, If the call comes through Fully Authenticated (Green) then it is safe to proceed without asking for Name, DOB and Zip Code.
What does Rejection Code 70 NDC NOT COVERED mean?
This drug is not in the prescription plan's formulary, and either is not covered and is excluded even if a PA is submitted, or it will require a PA review by the plan if the drug is medically necessary.
Which button in the Insurance tab will automatically populate the patients pharmacy benefits?
Check Pharmacy Eligibility
Where would you locate in SPRx if the patient has authorized for MDO to schd on their behalf.
Multiple choice answer
1. Patient Preferences
2. Priority Comment
MDO is on the backline and they have an approved PA but claim is not going through. Which department are you transferring the call to?
CARES (Resolution Team)
"Was the caller fully authenticated before the transfer?"
An Edit Failure Task is on the patients account and the patient has a DNF code 96 on the account. How would you remove the Edit Failure task?
1. If an order is not placed, place a refill order for the patient
2. Reach out to Account Solutions to have DNF code removed (BUMPED).
3. Once DNF code has been bumped, process claim and remove EDIT FAILURE TASK
What information is needed from the patient in order to add insurance on file ?
1. Name of Insurance Plan
2. Member ID
3. RX BIN
4. RX PCN
5. RX Group #
6. Effective Date
If a patient calls and says their MDO sent over a RX but you are not showing it in the system or pending which tab in SPRx can you click to check for incoming rx?
Intake Search
Pt stated when they got their order the RX was warm and they are not sure if they should use the RX. Who would you transfer the call to ?
RPH Stability ext. 1036641
If the INBOUND CALLER has only identified patients Name and DOB what other possible identifiers can the PSR use to fully authenticate the account?
Third Identifier Options:
How would you resolve rejection M/I PT residence?
1. Reprocess Claim
2. Confirm the patient’s place of residence and add this to Missing ECS screen field 384-4X.
Example: Home
What rejection must we get from Pharmacy Benefits first before we submit the claim through MAJ?
Rejection Code 816: PHAR BNFT EXCL, COVD MEDIC
Pharmacy benefit exclusion, may be covered under patient’s Medical Benefit.
The patient wants to know if their RX can be sent automatically. Where in SPRx can you check to see if patients RX is eligible for automatic refill?
Easy Refill Maintenance Tab
If any of these scenarios occur on a call where would you transfer the Patient:
Account Solutions Ext. 103-7267
When making an Outbound to Third Party (MDO, Insurance, Nursing home, Copay Assistance), what is the correct greeting?
Hello, this is (User’s first name) From CVS Specialty pharmacy, I’m calling today regarding a mutual patient (with brief description without releasing PHI/PII). Before we continue, I need to advise [The following phrase MUST be read verbatim] this call may be recorded or monitored for quality purposes.
When processing the claim you get ECS Rejection Code 41 SUBMIT BILL TO OTH PROC/PRIM PYR. What does this rejection mean?
The patient might have another insurance plan as their primary coverage and this plan will not cover the product or this plan might be the secondary coverage and must be processed after the primary plan has paid.
When changes are made to the insurance or copay, or when new insurance is added or new copay assistance information is added, what button must be pressed to refresh the claim before processing?
INS RE-RANK
Which tab in SPRx allows you to add a Prior Authorization to the account manually?
Insurance Tab
MDO is calling to start a Prior Authorization but the patient has Blue Cross Blue Shield Insurance. What are the next steps to assist the MDO with starting a PA?
Advise the MDO to contact Patients Plan. We DO NOT Handle BCBS Pa.
ex. PA code 4812856
1. Copay Pa Code
2. Reprocess Claim
3. Add Pa Code to Prior Authorization tab within the claim
Patients insurance is showing as termed. You have already did a check eligibility and confirmed with patient that the insurance we are processing is correct. What is the next step?
Advise the patient to call their insurance plan. We do not call the insurance plan for termed insurance rejection.