Benefit Investigations
Medical and Pharmacy benefits will be investigated within (X) business day(s) of a complete enrollment.
What is 1?
In over 90% of cases this is required.
What is a prior authorization (PA)?
HAE stands for:
What is Hereditary Angioedema?
This is the route of administration for RUCONEST
What is self-administered and intravenous (IV)?
When we get new insurance, we need to open a BI SR with this type of subtype.
What is "New Insurance"?
Case Managers should be calling (X) benefits before (X) benefits.
What is pharmacy and medical?
This is done to inform the patient of a reimbursement status update and primarily, to prepare them for a call to schedule their order of RUCONEST, share Copay information (if available), and confirm Copay Assistance options they may qualify for.
What is the PA Approval Call to the Patient?
These are three (3) types of HAE.
What is Type I, Type II, HAE with normal C1-INH levels (Formally known as Type III HAE)?
You may use this app to track swells
What is the HAE & Me APP?
We must call the payer if the PA has been (X) to confirm the details.
What is approved.
This call is completed to confirm insurance is active and plan details such as plan effective dates.
What is the call to the Medical Benefit for Eligibility?
This role is responsible for PA/Appeal oversight and provider/RAD assistance on HUB submissions
Who is MAO/Paige D.?
These are supporting documents for HAE Diagnosis and RUCONEST Treatment
What are HAE Diagnosis, Labs that show a deficiency, Clinicals, Letter of Medical Necessity, Attack History, Testimonial Letter, Photos of Swelling
This tool can help patients feel more comfortable with self-injection.
What is a vein-finder?
This pharmacy benefit is included within the overall health insurance plan, often managed by the same entity.
What is a carved-in arrangement?
The group of people that will be given payer requirements for coverage and action items that they will need to take to obtain coverage for RUCONEST.
Who are providers?
A resource available for CMs/MAO to utilize for published payer policies available online or compiled by the Pharming NAD Team.
What is the RUCONEST Coverage Workbook?
True or False: Hereditary Angioedema can occur with no family history.
What is true?
This is the site of care administration code.
What is 12 (Home Infusion)?
If we receive complete PA approval information directly from this entity, we do not need to call the payer to validate the information.
What is the Specialty Pharmacy?
There is no pathway to RUCONEST coverage or all pathways are exhausted
What is RUCONEST is "not covered"?
This is done to confirm the Specialty Pharmacy can bill under an approval and ship the patient's home for self-administration and confirm the patient's Copay amount (if possible)
What is the PA Approval Call to Payer?
Patients with HAE are typically missing this inhibitor.
What is the C1-inhibitor (C1-INH)?
The goal route of delivery and administration for RUCONEST
what is a medication shipped to the patient’s home and self-administered by the patient?
We should (X) tell the Pharmacy Benefit that Ruconest is covered through Medical
What is never?