Formulary
How are drugs listed in the list of covered drugs
What is by Medical Condition or Alphabetical Listing
Where do SPP members have to fill their Specialty drugs
Fairview Specialty
What is the standard turnaround time for a coverage determination
72 Hours
What is it called when their are limits to the quantity of the drug covered per month
Quantity Limit
A prior authorization is needed depending on your age and the specific drug prescribed.
Age Requirements
The restriction/limitation for diclofenac sodium topical gel 3 %
What is PA: QL (100MG per 21days)
What does rejection code 76 mean, and where can you send these request in FUSE
PLAN LIMITATIONS EXCEEDED. This may be the result of rolling quantity limits. If you see this rejection on a member's pharmacy claim, Save the claim for research, detail the question, and send the case to the ResearchWB. The CSS team will triage these requests from the ResearchWB to the Pharmacy team as needed.
What are the 2 FUSE tasks that can be used to initiate a coverage determination
Pharmacy Claim Inquiry and Check Formulary
What type of drugs are covered without a Prior Authorization
Preferred Drug
Drugs and products that are available for purchase without a prescription.
Over-the-counter drugs
Where can an PAMP member find the list of Over The Counter (OTC) Drug list within the Formulary
What is on page 202 or after the index
What drugs need all components to be included in order for it to successfully process. If any of the ingredients are not a covered drug, this drug will reject accordingly.
Compound Drugs
When initiating a coverage determination, which option should be offered first?
Warm transfer to ESI
What is it called when drugs require approval from UCare before you fill your prescription
Prior Authorization
A health plan that helps pay for prescription drugs and medications.
Prescription Drug Coverage
What is a list of covered drugs?
A list of covered drugs includes the prescription drugs covered by UCare. The drugs on the list are selected by UCare with the help of a team of doctors and pharmacists. UCare will generally cover the drugs listed in the list of covered drugs as long as the drug is medically necessary, the prescription is filled at a UCare network pharmacy, and other requirements related to the drug are followed. Most drugs and certain supplies are available up to a 30-day supply. Certain drugs you take on a regular basis for a chronic or long-term condition are available up to a 90-day supply and are identified on this List of Covered Drugs as 90-day.
When talking about Coverage Determinations to a member what should you advise them
This review does not guarantee the drug will be approved for coverage or the cost of the medication will change. If the review was not favorable, the letter will include a form to file an appeal if you would like to take further action.
What is a Coverage Determination
A coverage determination is a decision that is made about a member's pharmacy benefits and coverage, or about the amount the member will pay for their prescription drugs.
What is it called to identify a drug used for complex conditions and require Fairview Specialty Pharmacy to fill your prescription.
Specialty Drug
Is approved by the Food and Drug Administration (FDA) and has the same active ingredients as the brand name drug. It produces the same clinical effect as the brand name drug.
Generic Drug
This is where to look to find out if a Cinqair injection has any limitations or restrictions
What is the 2022 Medical Injectable Drug (Part B) Authorization List
For extra bragging rights: Does Cinqair have any restrictions?
This is a mental health platform from Express Scripts. It is a digital cognitive therapy program that teaches patients coping skills to help them respond to mental health issues and offers a positive path forward to help people care for insomnia, anxiety, or depression. This platform will be rolled out to Medicaid and Medicare Dual members.
SilverCloud Mental Health Platform
When determining that a claim processed correctly, what steps should you take
Review the Formulary, View Benefits, Review F14 for Prior Authorization
What is it called for Certain oral oncology drugs are limited to a 14 or 15 day supply per fill (depending on package size) for the first 90 days of therapy.
Day Supply Limits
Is an FDA-approved drug (most often an injectable prescription drug) that is highly similar to an already-approved product. It has no clinically meaningful differences in terms of safety and effectiveness.
Biosimilar drug