What is a formulary?
A formulary is a list of drugs that are covered under a members plan.
Tell me 2 ways I can tell if a member has pharmacy benefits?
The member is showing active in Prime. The member has an R in their benefits in CareRadius
What does rej code 75 mean in prime?
The drug is formulary and requires a prior authorization
How can I tell if a member needs a New case or a PCR case through the drug criteria?
The policy implementation portion of the drug criteria will show either "Criteria Update" or "Criteria Change" Update is just a minor update to the criteria where as Change is a change to the criteria. We would load a new request for review if there is a Change.
If you are loading a case by fax that has missing information on it, what fields in Advanced edit need to be updated?
If information is missing only the Rcvd date/time need to be updated to the date/time stamp on your fax.
How many formularies do we (Commercial BCBSNC) have and what are their names?
3 - Enhanced, Essential, ASO NetResults
How can I tell if a drug is covered through the members Pharmacy benefit or Medical benefit?
If the drug is showing on prior review plan and limitations page with benefit "Pharmacy" the drug is covered under pharmacy or benefit "Medical" it is covered under medical. For drugs that have both pharmacy and medical, look for "Self Administered" for pharmacy and "Administered in an office setting" for medical.
The submitted claim is more than the allowed/approved amount, which can be the member is trying to fill too soon, or they are trying to fill for more than the allowed amount for the time frame the claim was submitted for. (Mbr is approved for 1 a day and the provider submitted for 30 for 28 days)
How many days must a provider wait between a denial and a new case, and what date do you use to calculate the days?
Providers must wait 180 days from the date of denial, the date the denial letter was sent and the case was close.
If you are loading a PCR case and information is missing what fields do you update in Advanced edit?
PCR cases do not follow the same timelines so both the Rcvd date/time and the AIR (All Info Rcvd) date/time would be when the fax came in.
What does Non-formulary mean?
Non-formulary means the drug is not on the members formulary
What are "Carve-outs" and where do I find the "Carve-outs" for a specific group?
Carve-outs are drugs that an ASO group has decided they do not want to cover and have carved out of their benefit. You would find these on the "Crosswalk"
Can a drug reject for more than 1 rejection code? How do you view details on the rejection, what "hot-key"
Yes, F10 from the claim in prime will let you see more details on the rejection.
It would be a PCR, 180 days from 06/09/20 is 12/06/20. It must be exactly 180 days from the date of denial for it to be a new case if nothing else has changed.
If I rcvd additional information on a case in Urgent OR 1 folder, what if any field do I update in Advanced Edit?
You would only update the date/time stamp if the info you received, that you are attaching to the case is the missing information needed for the Rph to review the case. You would update the AIR field only with the date/time you received the additional info. Since it is in Urgent OR1 folder outreach has not been made so no other field should be updated.
What is the difference between and Open and Closed formulary and what plans are Open and which are Closed?
Open formulary, only the drugs on the formulary list are covered if it is not, it is not covered. (Enhanced and ASO NetResults are Open) Closed formulary if the drug is not on the members closed formulary list they can submit a Non-Formulary request for review of the drug.(Essential plans are on a Closed formulary)
How do you know if a member has a Medicare (part D) policy or a Medicare Supplement policy and where do you send Medicare (part D) members and Medicare Supplement members?
Medicare supplement policies start with YPZW and YPZJ. Medicare part D policies are YPWJ. Medicare part D members go to MedD Requests, Medicare Supplement policies you return to the provider advising the member has a Medicare Supplement and to contact Medicare Supplement directly.
What are 3 reasons for a 70 rejection code?
1. The Drug is Non-formulary or Medical Necessity
2. The Drug must be filled through a specialty pharmacy
3. The drug has a benefit limitation
If I receive a request for Humira for the Dx of Psoriatic Arthritis and I get a new request for the Dx of Plaque Psoriasis, would I review this as a new case or a PCR?
It would be a new request since the Dx that the drug is reviewed under (the criteria) has changed.
When do you update the ADIR field?
Only those working in the Urgent OR1 folder will update the ADIR field, this field is just to indicate when we made the 1st request to the provider for missing info so if you are not working the Urgent OR1 folder you would not update this field.
What is the difference between Non-Formulary and Medical Necessity?
Non-formulary, the drug is NOT listed on the members formulary (Only the closed Essential plans have Non-formulary reviews) and we would need a non-formulary review for any drug that is not on the members formulary list. Medical Necessity, the drug is listed as (MN) medical necessity on the members formulary list (Only the open ASO NetResults plans have Medical Necessity reviews) - They are processed the same but we need to understand the difference
How do I know if a member has a StatePPO policy?
The members policy will start with YPYW and their plan type will show SPPO.
What is a benefit limitation, and name 2 types of drugs you may see a denial for benefit limitation?
Benefit limitations is a limit on the quantity of a drug a member can fill due to a limitation in their benefits, this is different than a carve out. IR Opioids and Fertility drugs as some of the medications that have benefit limitations on them.
If you receive a request from Dr Lassiter from Emergo Ortho and you get a new request from Dr Swann that is also from Emergo Ortho, same address, fax and phone#. Would you load it as a new request or a PCR?
Since both providers are from the same practice it would be a PCR. If the providers were from different practices it would be a New request.
If you receive additional information on a case that is in the Callback folder what do you do with that case?
If the case is in the Callback folder waiting for UMS to complete and letters have already been sent on the case you will need to ping a PSS to have a UMS complete the case so you can attach your request as a PCR with rcvd date/time and AIR the date/time of your fax. If letters have not been sent on the case you would attach the additional information, update the AIR field and move back to the pharmacist folder for review of additional information.