Pharmacy Assessment Part 2

When verifying prescription drug (part D) benefits in RxConnect, how will you know if a medication requires prior authorization approval from HCPR?

• “Prior Authorization”, “B vs D Determination”, or “Step Therapy” appears under the Coverage column

• “Quantity Limits” appears in the Coverage column

• When the medication is Tier 4 or higher.

A member expresses concern over the high copay cost of their prescription that their PCP states is the only effective medication for them. What is the best course of action?

• Show empathy and advise them this estimate is accurate based on their current plan.

• Advise the member they can request a tier exception and warm transfer them to HCPR.

• Provide cost saving alternatives they can discuss with their doctor.

When researching a denied drug claim in RxNova Call Connect, you find error code “082” listed under the Errors & Messages panel, what does this mean?

• The medication is a CMS excluded drug.

• The member is attempting to get an early refill.

• Pre-authorization is required through HCPR.

If, while researching a different denied drug claim, you notice error code “221” is listed in the Errors & Messages panel, what does this mean?

• The medication is for a drug covered under Part B only.

• This is a duplicate charge for a claim previously processed.

• The medication is covered, this is an informational error only.

When confirming the amount (if any) a member owes on a drug claim, which dollar amount in RxNova Call Connect represents the member’s responsibility?

• Plan Paid amount

• Patient Paid amount

• Sub Ingr Cost amount

Which RxNova Call Connect option provides the status of check issued to members who submit a paper claim for Direct Member Reimbursement (DMR)?

• Reimbursement

• Formulary

• Pharmacy

How can you tell when a drug claim requiring correction was adjusted and reprocessed in RxNova Desktop?

• A date is visible in the Adjustment date field.

• The claim source will always show “DMR Long”.

• The Plan paid amount will show a dollar amount.

The status of a prior authorization for a prescription drug can be found where in CRM?

• Auth/Referral Summary tab under Pharmacy Authorization tab

• Contact Handling Alerts section

• Policy Member page under the Details tab

If the indicator under the RxNova Call Connect Dual Coverage panel shows “S”, what does this mean?

• The member does not have other insurance coverage besides Humana.

• The member has other insurance (OI) – Humana is secondary.

• The member has other insurance (OI) – Humana is primary.

Mail Order demographic Information edited under the Demographics section is limited to ____________.