PAP
What is program FPL?
at or below 500% FPL
What is the day supply for QS?
15 days
What is the days supply for a Bridge?
15 days
What assessments need to be completed upon receiving a referral?
1. Referral consent assessment
2. Benefit assessment
3. Patient Welcome call assessment
4. Provider Welcome call assessment
5. Service review (upon pt welcome call)
6. Hub Inquiry (upon receiving referral)
What is always needed before proceeding with any case?
Patient consent
What are the 3 different PAP types (buckets) that a patient must fall under to be eligible?
2. Functionally Uninsured (PA Denied)
3. Underinsured (Financial)
How many QS's can a patient receive?
up to 4 (15day) supplies
How many bridge supplies can a patient receive?
up to 4 (15day) supplies
Where are we documenting the pt's subtype once obtained?
1. progress note upon completing welcome call
2. User defined Field
What is the time frame to triage a script received to an SP?
4 hours
How is proof of income verified?
Utilize Experian
- IF pt's service review does not match experian, obtain physical POI (fax, email, etc)
When does a patient qualify for QS?
when a payer coverage decision is delayed beyond 5 business days.
Can a patient who has been off therapy for 3 months qualify for bridge?
No, as the bridge is only for a lapse in current therapy.
What lists can we schedule a patient delivery out of?
List A and B ONLY
When an RX needs to be triaged, how do we determine where it is sent to?
1. preference listed on PEF
2. if there is no pref, then send via round robin.
How many denials are needed for PAP?
How does a patient qualify for Quick start?
1. Must be new to therapy
2. Patient must be 18 years of age or older and have a GIST or SM diagnosis with an FDA approved indication (see Business Rules for ICD-10 codes).
3. Patient must reside in the US or its territories.
4. Payer coverage decision must be delayed beyond five business days.
Can an off-label patient qualify for bridge?
No, the patient would only qualify for PAP of the service offered by YBP.
What lists are a monthly verification run out of?
List 3 and B ONLY
What pharmacies can dispense Ayvakit?
1. Biologics
2. Onco
3. IOD
4. Caremed (free good only)
Once a patient is approved for PAP, what letters (word merges) are sent?
1. PAP shipment notification to MDO upon scheduling delivery
2. PAP shipment approval letter to patient (either straight PAP letter OR MCR-D letter) upon scheduling delivery.
A clinical trial patient coming off clinical trials qualifies for a quick start how?
They do not qualify for a quick start. They can qualify for a bridge supply as they are currently on therapy.
What can cause a Bridge to be needed?
What are the steps to logging a free good approval?
In no particular order:
1. pop up
2. payor
3. progress note
4. service review
5. change payor in order and push to 4
What is the copay card maximum?
$25,000