Milestone 1 Review

Mrs. Blaire calls you to refill her husband’s medications. She tells you that she takes care of this for him all the time. You are able to obtain Mrs. Blaire’s husband’s name, date of birth, zip code, and member ID number. What must you do before placing an order for Mr. Blaire’s medications?

• Verify the strength and dosage form of each medication.

• Ask Mrs. Blaire if her husband is aware that she is calling on his behalf.

• Mrs. Blaire is already fully authenticated, so no additional authentication elements are necessary.

• Verify the address the medications are being shipped to.

Mrs. Johnson calls in to place a refill on her Metformin; you see that she does not have any refills left. You advise her that we’ll reach out to her doctor to get a new prescription. You realize Mrs. Johnson should enroll in the Automatic Refill and Renewal at Mail program so this does not happen again. Where can you go in PeopleSafe to see if this program is offered to her?

• Order Status screen

• View Activity tab

• Client Program Offerings link

• Clicking on the prescription number

Mrs. Reddick is a member calling to verify if her pharmacy is in our Preferred pharmacy network. Prior to answering her question, what document could you reference to ensure you gathered all the necessary authenticating information?

• MED D – 2015 Readiness Plan Design Reference

• Consultative Call Flow (CCF) Process CCR Tip Sheet

• HIPAA Authentication Grid

• HIPAA Issue and Disclosure Escalations

Mr. Hickman is calling to inquire as to whether he is eligible to enroll in a PDP. Which of the following would prevent Mr. Hickman from being eligible to enroll?

• He is a U.S. citizen.

• He is entitled to Medicare Part A and/or Enrolled in Part B.

• He permanently resides in the PDP service area.

• He lives abroad.

Mr. Parker calls in wanting to know if his drug plan will cover Tylenol Cold medicine since his doctor just diagnosed him with a cold. You should advise Mr. Parker in the following way:

• Since over the counter drugs typically aren’t covered, first run a Test Claim before advising Mr. Parker.

• He’ll need to contact the pharmacy to see if they can approve it.

• Over the counter drugs are not covered; however, you can submit an appeal for him.

• Yes, he will need to submit a paper claim within 30 days of purchasing.

A member calls in to find out why her Fentanyl, a C2 controlled substance, is limited to a 30 day supply. You see the member lives in Illinois, and advise her:

• The state of Illinois, where the prescriber is located, has state restrictions that apply.

• Those are the restrictions set by CVS Caremark.

• She will need to contact Medicare to see if they will override the state law restriction.

• She needs to file an appeal to increase the day supply.

Which of the following is NOT considered to be PHI?

• Beneficiary’s Name

• Beneficiary’s Date of Birth

• Beneficiary’s Address

• Plan Design Information

You have fully authenticated Mrs. Worthington with her full name, date of birth, zip code, and member ID number. She tells you she needs to refill her medications. Upon accessing the Order Placement screen, you see there are 5 prescriptions available to refill. After asking her which medications she needs to order, she says that she can’t remember exactly which ones and asks you for the names. What is the correct next step to assist her with refilling her prescriptions?

• Provide hints to help her try to remember the names of her medications.

• Advise her that she must be able to name all the prescriptions she needs refilled, otherwise you cannot place an order.

• Tell her the names of the medications she has available to refill.

• Suggest to Mrs. Worthington that her doctor call us to provide the names of her medications.

Alan Michaels calls to check on the status of his request for two more pharmacy benefit cards. You open the task notes and see that the issue has a closed status. What should you do next?

• Call the Senior Team to have them research the issue.

• Advise Mr. Michaels that the request is still processing

• Advise Mr. Michaels that he should receive a call with the resolution in three business days.

• Advise Mr. Michaels that cards were ordered on January 4.

Mrs. Brooks received a new prescription from her doctor, Dr. Evans, for Levothyroxine 25 mcg tablets. Dr. Evans instructed her to take one tablet in the morning and two tablets in the evening and provided her with a 90 day supply prescription. When Mrs. Brooks contacts CVS Caremark to find out how much her medication is going to cost her, what quantity will you enter when performing the price estimate?

• 90

• 360

• 120

• 270