Formulary & Coverage
This deliverable is used when explaining tiers, PA requirements, or offering alternatives for non-formulary drugs.
Formulary Status
When assisting with claim rejections, agents must do these TWO things according to QA standards
Explain the rejection in simple language AND offer a solution
When assisting with mail-order, the agent should ask if the member has this much medication on hand
14-Day Supply
When a member reports an app bug or glitch, agents must use this specific resource to report it
#pbm-mobile-app Slack channel
According to the deliverables guide, you should select a deliverable even if the member didn't necessarily ask for this information. If the AMOUNT was discussed, this deliverable should be chosen.
Price of Medication
For non-formulary medications, PHARMACISTS should offer formulary alternatives and ask if they can do THIS.
Contact the provider to discuss alternatives and request a new prescription
This deliverable is selected when you assist a member with the following claims: vacation, lost med, or CEM
Override
When explaining DMR to a member, agents must provide this information along with the timeline for approval
The reimbursement amount could be less than what they paid
What are THREE key pieces of information needed to appropriately select the Eligibility deliverable?
Effective/termination dates, whether they’re active and eligible, and dependent coverage status
A member calls about a refill rejection due to “too soon”. You explain RTS and offer to enter an override. You should select these three deliverables
Refills, Claim Rejection, AND Override
When a member disagrees with formulary alternatives, PHARMACISTS must explain this option that allows providers to request coverage exception.
Prior Authorization
A member chats in because their prescription was rejected at the pharmacy. Even if you don’t resolve it completely, you should select this deliverable if you discussed the rejection
Claim Rejection
A member asks about their WAGMO package location. You provide tracking details. Select this deliverable
Shipping Status
A member asks about their DED and MOOP. You explain both. This deliverable should be selected
Accumulator
A member’s medication is on backorder. According to the deliverable steps, agents should offer to do THIS
Call three pharmacies to check inventory
When providing formulary status, agents must give accurate information on all of these coverage requirements, not just the tier
Tier, PA, Quantity Limit, and Step Therapy
After entering an override authorization, agents should offer to do THIS proactive step to help the prescription process
Reach out to the pharmacy to reprocess
A member paid cash for a prescription that should’ve been billed to RW. Within 7 days, agents should do THIS
Reach out to the pharmacy to reprocess
When ordering ID cards for members, agents must also do THIS to ensure the member has immediate access to their information
Explain card information can be found in the app and check for problems
For backorder situations, agents should also do THIS additional step to help find alternatives
Call the pharmacy to check for similar medications or strengths in stock