Core Confluence Review

When would we check for "CVS/Caremark"

• When a claim pays and Caremark is listed in BET under "Plan Information"

• When the drug is found on the Florida specialty drug list and the member is not a SaveOn member

• When Caremark is listed in the Client Name in the summary details

• When there is no claims for our requested drug in RxClaim

Answer explanation

Only in FL at section 5.4 Identify specialty drugs

We always fill out these fields when No QL applies

• Max Quantity Field

• Requested Quantity Field

• Quantity Units Field

• None

Answer explanation

We leave everything Clean =)

Which of these statuses are examples of "Open" cases

• Open-MRIoA Submit

• Pending-Outreach Toll

• Resolved-Approved

• Pending OutreachP2P

• Open-Outreach

Answer explanation

Whenever you see "Pending" think of it as Open

We do the process of "Merging" to Outreach cases

• True

• False

Answer explanation

We check for TBO when

• The claim rejects for 75 and 76 at the same time

• The Intake Note states

  TBO: Yes

• There's a "O" present on our claim

• There's a pop up stating Note to Tech : TBO applies

Answer explanation

These documents should always be sent to MRIoA

• Current Case File

• Criteria Set ( Most Recent RPh criteria set for each denied Program)

• Prescriber Additional Information

• Other

• PARQSTFRM

Answer explanation

We look for "ADDLINFO"

We enter 3 PAs for Wegovy when...

• It is Over the QL and GPI/NDC list the claim is pulling is not detailed

• It is within the QL and the GPI/NDC list that the claim is pulling is detailed

• The claim rejects for 70 at the pharmacy

• It is within the QL and the GPI/NDC list that the claim is pulling is not detailed

Answer explanation

We Run our call notes for

• New cases

• Withdrawn Cases

• Auto-approvals

• Auto-review

• NCR - Non-Clinical Review

Answer explanation

We have some special ones that we enter call notes twice

We send our case for outreach at ________

Answer explanation

When AI is received for a Denied HIM CE or CE/UM in FL we set the classification type as

• Initial Review

• Additional Review

• IRO Review

• IRO Preliminary

Answer explanation