RPH OR PCT
Who would you contact and what SOP would you use?
contact PCT using SOP 2.27 Tablet Identification
Aaron called in wanted to know why Tricare will not cover his medication. You located the claim and saw rejection 71. What SOP would you use to explain the reject reason
Rejected claims 9.2
Allen just ordered a C2 medication. He wanted to know how long shipping would be since he only has 5 days of moh. What SOP would you use?
DOD Turn-around-time (TAT) Job aid
Can the beneficiary get reimbursed for the copayment paid to their OHI?
What SOP would you use?
Only if Tricare has not processed the claim as secondary
DOD- Other Health Insurance (OHI) FAQ
Mbr called in requesting an EOB that is more than 27days old.
What SOP would you use?
DOD- Explanation of Benefits (EOB)
Ms. Mary called in wanting to refill a prescription. She is having trouble recalling the name of the medication but is attempting to order based on the use and directions of medication. Who would you contact and what sop would you use?
PCRPH using SOP 2.3.1 using under calls requiring an offer of counseling by PCRPH
Retail pharmacy called in stating that they are receiving reject 88 DUR - safety edit rejection
Who would you refer them to and what SOP would you use?
DOD PHD SOP 9.2
Elizabeth called in upset because on Friday she added 2 day shipping to her order. It is now Monday and her order has not been delivered. What SOP would you use?
Article Number 000099481 What is the cost of express scripts expediated shipping
it explains that expediated shipping does not include delivery on weekends or holidays
I canceled my Medicare prescription plan to use my Tricare benefit but my new prescription order with Express Scripts still rejected.
What SOP would you use?
Mbr would need to send proof of disenrollment to DEERS Support Office to update their record
DOD- Medicare Part D FAQ
Retail pharmacy called in stating that they are trying to process claims for a newborn beneficiary. You found the newborn in the system under a placeholder name ("Baby boy, Baby girl")
What would you advise the caller? What SOP would you use?
Article Dod- Newborns, Adopted Children and Pre-Adoptive Children
Mr. david called in stating that he only received an amount of 70 tablets but the prescription was for a qty of 90. Who would you contact and what sop would you use?
PCT using SOP 6.2 Replacement order- shortage
Shannon called in wanting to check on her direct claim status. What SOP would you use to locate it?
Claim Status- How to locate, SOP 9.1.2
Sarah called in stating that her husband is currently active duty and believes that she should not have a copay for any of her medications since her husband does not. What SOP would you use?
Article Number 000065147
DOD -Active Duty Status
What SOP would you use? How would you explain it?
An online COB occurs when a pharmacy processes a claim under multiple insurances or discount plans.
DOD- Other Health Insurance (OHI) FAQ
Mbr called in with complaints about home delivery issues. You put in a concern with through CSP but the mbr still is not satisfied.
What else would you advise? What SOP would you use?
SOP 2.15
Provide callers with the proper address to submit a written complaint. Complaints can also be emailed.
Ms. Ann called in confused about the medication name on the bottle received. The bottle had the generic name with substitute next to it, you confirmed that she received the generic name but she was still unsure. Who would you contact and what SOP would you use?
Eric called in stating that he submitted his direct claim form 2 weeks ago and still has not received his reimbursement check in the mail. What SOP would you use?
DOD Turn-Around-Time (TAT) Job Aid
Mbr called in confused as to why she has a copay on her medications. She explains to you that she has OHI and should not have a copay.
How would you resolve the call?
Explain to mbr that even with OHI Tricare holds everyone to their copay structure. Anything left after primary that is equal to or less than the Tricare copay structure will be deemed patient responsibility.
What Happens when the beneficiary has met the plan max for OHI?
How would you explain and what SOP would you use?
The beneficiary would need to send in a current EOB/letter from the OHI. The letter must verify nonpharmacy coverage due to reaching plan maximum
Mbr called in stating that she has a discount card and wanted to add it to her account.
What SOP would you use?
Discount Cards
Express Script does not accept mail in coupons or discount cards
Mr. Paul called in requested faster shipping on his order. The order is now in fulfilment and shipping cannot be changed. He is frantic with no moh asking is there any way the order can be rushed. Who would you contact and what SOP would you use?
PCT, SOP 7.1 Emergency Case
Jackson is currently filling out his DD2642 claim form. He wants to know what all would need to be on the receipt received from the retail pharmacy. What SOP would you use?
Direct Claim Checklist under Terms drop down
Mbr is upset that they received a medication that they did not order. You explain that the order was processed because their doctor submitted the prescription. They are now demanding a credit because they did not authorize the fill.
How would you resolve the call and what SOP would you use?
SOP DOD Credit Requests and Return Mailers SOP 27.12
EXPRESS DOES NOT ALLOW COURTESY CREDITS
You can offer special handling do not fill a prescription until the patient approves
- Special Handling Request Procedures for Patient Care Advocates
Mbr stated that retail claim is rejecting for Medicare D but they do are not enrolled.
How would you resolve the call, what SOP would you use?
Advise the beneficiaries to have their pharmacy process their Med D coverage as commercial.
DOD- Medicare Part D and Tricare
Rebecca just received her fill for nurtec in the mail. She was confused as to why she only received 25 tablets in the mail. You checked drug coverage and it states the plan will only cover 25 tablets within a 90 rolling day period.
What would you advise and what SOP would you use?
Let the member know that her plan a qty limit and will only allow 25 tablets within a rolling 90 day period and that if she needs more her doctor would need to submit a PLA for qty limit override.
SOP What's a PLA (Patient Level Authorization)
SOP 12.3.1