Achelle 👸
True or False: Not all self-administered medications are eligible for benefits
Answer: True
True or false: Veterans Administration facilities (VA) do not bill prescription claims online directly, but they can send paper claims to the appropriate Pharmacy Services address listed.
Answer: True (KMT: 29936)
True or False: Any claims for outpatient hospital and professional services that include a J-code, DOES NOT require an NDC (National Drug Code) to further identify the medication billed by the J-code.
Answer: False
From KMT 15633 - Site of Care: Infusion Therapy
TRUE OR FALSE
Pharmacy Services is responsible for intake of all prior authorization (PA) inquiries/requests for medications (Part B and Part D) and B vs. D coverage determinations.
TRUE KMT 18864
True or False: For Regence members, the specialty pharmacy is not required by BCBSA rules to submit the claim to the Blue Plan where the ordering physician is located.
Answer: False (pharmacy is required by BCBSA)
I is the processed through Pharmacy Services. Retail prescription claims are processed through the RxClaim system, not SDS/Facets.
Answer: Prescription claims (KMT:29936)
Yes or No: Do we need to ask the referring provider where the service will be performed at the time of the clinical preauthorization request?
Answer: Yes
From KMT 15633 - Site of Care: Infusion Therapy
Who is responsible if Caller wants pricing information for Part B medication being dispensed in an outpatient setting (for example, at a provider's office).
Regence Medicare CS (KMT 18864)
Drugs used to prevent/treat bone disease secondary to dialysis
Answer: Bone and mineral metabolism
Tru or False: Prime Therapeutics is the Pharmacy Benefits Manager (PBM) for plans that have prescription benefits administered by Cambia.
Answer: True (KMT 29936)
Yes or No: Do we need to ask the referring provider where the service will be performed at the time of the clinical preauthorization request?
Answer: Yes
From KMT 15633 - Site of Care: Infusion Therapy
if a medication is not listed, We need to reach out __________ to verify that PA is not required, as called out in the above call handling table for Part B vs. D determinations
Pharmacy Services KMT 18864
True or False: Infusion therapy can be done in a doctor's office, the member's home, an infusion center, or an outpatient facility.
Answer: True
Claims for prescription medications purchased outside of the United States and U.S. territories will not be paid for any member unless:
Answer:The member is living abroad and the prescription medication was purchased in the country in which the member is residing. The prescription claim relates to a medical emergency while traveling outside the United States.
What is Infusion Therapy?
Answer: The process of administering a medication / drug intravenously (by IV). Infusion therapy (including chemotherapy) includes the services, supplies, and drugs associated with the therapy.
From KMT 15633 - Site of Care: Infusion Therapy
The Site of Care program:
Applies to members receiving infusions in Idaho, Oregon, Utah, and Washington. TRUE OR FALSE
TRUE KMT 30447
TRUE OR FALSE Medical Drug review letters (PA, appeals, etc.) are available in RADAR and are loaded under the Provider’s number.
FALSE -Member's ID number KMT 18864
TRUE OR FALSE PA requirements for certain Part B Step Therapy Medications will be enforced.
TRUE KMT 18864
Responsible for quoting medical benefits for medications covered under Part B; including injectable medications such as J-codes.
Please refer to Benny Booklets for quoting.
Medicare CS KMT 18864
TRUE OR FALSE
Two authorizations are required for coverage at a costly outpatient facility:
Clinical authorization for the drug
SOC exception
TRUE KMT 30447