Formulary
fluoxetine hcl 20 mg/5ml Solution is on this tier
What is tier 2
These drugs are generally administered at a doctor's office (Example: Remicade for arthritis).
What is Medicare Part B
These are the 2 FUSE tasks that can be used to initiate a coverage determination
What are check formulary and pharmacy claims inquiry
This is a prescription claim that takes the member from their current coverage phase into the next coverage phase (deductible to initial; initial to gap; gap to catastrophic).
What is a straddle claim
This is when the member is getting extra help with their Part D cost sharing
What is LIS/LICS?
The restriction/limitation for tacrolimus topical ointment 0.03%
What is QL (100 GM per 30 days)
This is where you can give the member an estimate of how much their drug will cost.
What is the Drug Calculator
If Drug A and Drug B both treat your medical condition, UCare Medicare Plans or EssentiaCare may not cover Drug B unless you try Drug A first. If Drug A does not work for you, UCare Medicare Plans or EssentiaCare will then cover Drug B
What is step therapy
This is offered once you have done all the research (including calling CSS if necessary) and determined the denied pharmacy claim processed correctly.
What is an appeal
This is the delegated business we can refer members to if they need help paying for prescriptions
What is My Advocate/Senior Linkage line
LATUDA 120 MG is this.
What is non- formulary
This is a service to support members with multiple health conditions and who take multiple medicines. To be eligible they need to have part D coverage.
What is Medication Therapy Management Program (MTM)
These are the 5 different types of coverage determinations for Medicare.
What are: Prior Authorization, Formulary exception, Quantity Limit exception, Step therapy exception, Tiering exception
ONDANSETRON HCL 4 MG tablet has this restriction, and you would offer the member this.
What is prior authorization to determine if it is Part B or D. Warm transfer to Navitus
This is the prescription payment plan portal name.
What is Simplicity Rx (SRX)
This is the abbreviation you might see on the formulary if a drug coverage is limited to certain manufacturers.
What is MFG
If you are a current UCare Medicare Plans or EssentiaCare member transitioning to a different level of care, you may be prescribed medications not on our formulary. While you are talking with your doctor to determine your course of action, you are eligible to receive a ___day transition supply of the drug since you are transitioning to a different level of care
What is 31
This is the procedure to follow if a member will be traveling outside of the United States and wants to know about getting their medications in advance
What is Save your task for research and route it to the research workbasket. Use the template on the Pega KA - Refill Too Soon
This is what you can do in Navitus if there is a COB issue regarding pharmacy or to see what the members cost share will be.
What is run a test claim
The members that are on LIS and getting extra help will not have this benefit stage.
What is the deductible
This is where to look to find out if a Cosela injection has any limitations or restrictions.
What is the 2025 Medical Injectable Drug (Part B) Authorization List
These drugs are not eligible for mail order through Costco
What are specialty drugs (Tier 5)
Verbally authorized callers cannot file this on behalf of a member for prescription drugs.
What is coverage determination
This is the rejection code for the reason stating that it is not covered under Part D by law.
What is A5
This is the Medicare payment plan name that offers help with Part D medications if the member is incurring high out of pocket costs.
What is M3P. (Medicare Prescription Drug Payment Plan)