Quantity
Requesting 1 tablet daily. Package size is 1000 EA
What is 30 tablets per 30 days?
Requesting 4 pens per month. Inject 0.75ML every week. Package size 0.75ML.
What is 3ML per 30 days?
There is a case for the same member, same provider and same medication and is currently approved until 8/7/2026.
What is a duplicate?
What workbasket would faxes needing to be triage be in?
What is Inbound Fax?
When a case is a duplicate, you can do this action on the case.
What is Void?
Requesting 2 tubes monthly. Package size 45GM.
What is 90GM per 30 days?
Requesting 0.40ML syringe every week. Package size 1 EA.
What is 4 syringes per 30 days?
Request received with new clinical information. There is a case for the same member, same provider, same medication, and was denied within 180 days.
What is an Appeal?
The case should be sent to this status when the clinical information for a PA or formulary exception did not meet the criteria.
What is Clinical Review status?
When a case was voided as a duplicate from more than 3 days ago, you should do this.
What is Resend Letter?
Requesting 1 vial every 4 weeks. Package size 1 EA.
What is 1 vial per 30 days?
Requesting 12 cans monthly. Package size 237GM.
What is 2,844GM per 30 days?
Medication is a Benefit Exclusion. We do not appeal these.
What is Admin Deny?
How would you process a case that is a Weight Loss Excluded group?
What is Admin Deny BE?
When a medication does not require a prior authorization, step therapy, formulary exception, and does not exceed QCD.
What is a No PA?
Requesting 1 pen every other week. Package size 0.5ML.
What is 1ML per 30 days?
2 syringes per month. Package size 1.17ML.
What is 2.34ML per 30 days?
The status of the case that was not needed or it had to be rebuilt.
What is Void?
This status is when a decision is made and you must quality check the letters. Check that test claims pay with all approvals.
What is the Pending status?
The medication is excluded from the plan.
What is the Admin Deny (BE, MC, WM) Workflow?
Requesting 1 tablet every 8 hours daily. Package size 100 EA.
What is 90 tablets per 30 days?
1 capsule PO QD. Package size 100 EA.
What is 30 capsules per 30 days?
MDO started an EPA case and did not finish.
What is Questionset Sent?
When a medication must be dispensed by a contracted specialty pharmacy, there is a drop down that must be selected.
What is CVS Specialty?
The folder on your desktop where all workflows can be found. This is a shared folder with the entire team.
What is Training Documents?