Eligibility
This information needs to be provided when member is active.
What is the type of plan, dates of coverage and the assigned pcp
This cost share is represented in dollar amounts.
What is a copayment?
If the provider has questions about the medication denial, they can speak to this department.
What is the pharmacy department?
When services require approval by the insurance company.
What is a Prior Authorization?
If the member enrollment does not match the state enrollment.
What is an eligibility discrepancy?
Total amount of cost share paid for the year.
What is the Out of pocket maximum?
Covered medications will be located here.
What is the formulary?
Prior authorizations are based on this.
What is medical necessity?
Enrollment updates are forwarded here.
What is the enrollment tier 1 call tracking box
The cost share that is represented in percentages.
What is the coinsurance?
This is the system where medication will be processed.
What is CVS Caremark? or Client Online Services?
A reconsideration of a denied service.
What is an appeal?
A term used when the member can't receive services when needed.
What is Access to Care issues ?
This cost does not count towards the MOOP
What are Monthly premium payments?
How the MP formulary indicates cost amount of medication.
What is the Tier pricing?
This department will handle the review of an authorization request.
What is the Utilization Management Department?
This is the email to have Medicare enrollment updated.
Transportation, vision and dental are considered these.
What are supplemental services?
When one medication requires the trial of another medication.
What is Step Therapy?
An expedited request must show proof of this.
What is to prevent serious deterioration of member’s health or jeopardize their ability to regain maximum function