Master Formulary
What is the first step when looking up a member's drug in master formulary?
Type in the member's Rx Plan ID
True or False: Prior Authorizations is required when a drug has specific requirements a member must meet in order for their plan to pay for that drug.
True!
What does DPAS stand for?
Drug Prior Auth System
This edit is used when a member is prescribed a drug that is not covered by their plan on ANY tier, but is not Medicare Part D excluded.
Non-Formulary coverage determination
What does a commercial member's ID number start with?
"W"
Which tool will you need for each phone call, whether the call is for a coverage determination request or just informational, that can be accessed directly through the Master Formulary?
Templates
Which tier would you find a specialty medication that requires a prior authorization?
Tier 5
1604 Referral Code is for..?
Quantity Limity Coverage Determination (QL)
A non-formulary medication will never have a...
Quantity Limit
HGS/Aetna restricts paper, pen, and sticky foods at your work desk. Most importantly, HGS/Aetna has a zero-tolerance policy for _____ on the floor.
Cell phones, and/or any other electronic device
When searching for a member's drug in Master Formulary, what is the next step after entering the drug GPI?
Select the medication from the Drug drop-down menu
This tool is used when a member's prescription is rejecting for hospice PA required, in order to determine whether or not Part D should pay it.
COS
Where in DPAS should you go to look up the member's prescription fill history?
List the type of coverage determinations we can approve without a pharmacist, given we have all of the necessary information.
Prior Auth, Step Therapy
What does an Aetna member's ID number start with?
"MEB"
True or False: When a medication requires a hospice coverage determination per the CVS claims tab in DPAS, a pop-up box does not appear in Master Formulary. Instead, you must read the Drug specific Messaging screen once the drug is pulled up in master formulary.
Hospice status for a member can be found in COS. What OTHER STATUS can be found for a member in COS, that helps to determine how Medicare will pay for a rejecting prescription?
ESRD (End Stage Renal Disease)
This field must be completed after selecting your TOPIC (in the TOPIC field) in DPAS
SUBTOPIC
This edit should be completed when a member has a contraindication to all meds required for step therapy treatment
Step Therapy Exception
When taking a break, what is the most important thing you should do before leaving your work desk?
LOCK YOUR COMPUTER!
In master formulary, when a drug requires a coverage determination edit, guidance questions must be followed and answered. Which button is used to obtain the outcome, in order to complete "Decision Tree Criteria Met" section of your template?
"Submit/Copy Notes"
A member called to initiate a prior authorization for his new medication. Based on the member's answers to the drug guidance questions, he has a medically necessary reason why he cannot meet the criteria. After documenting this information, you realize this is likely now a PA exception. What is your next step?
Call an RPh to assist
What two fields will you need to complete in DPAS, immediately after an RPH verbally approves or denials a coverage determination request with you, or once the drug guidance advises an approval?
"Next Step" & "PA Decision"
Mrs. Smith is calling because the pharmacy advised the copay for her new Rx is $200, and states it is too costly. Upon research you see that she is prescribed a specialty medication that is covered at 1 tab daily, but requires a prior authorization. Mrs. Smith was prescribed a quantity of 60 per 30 days. In what ORDER should you complete the necessary edits needed for her new Rx?
PA, QL, TE
Where is HGS headquarters located?
Illinois!