Coverage Determination Types in Medication Prior Authorizations Flashcards
What type of information can be used to approve Quantity Limit Exception Request?
* Quantity limit
* Patient diagnosis
* Claims data
* Criteria requirements
claims data
What is Medicare Part B?
* Brand, generic, and biologic medications
* Commercial Insurance
* The original Medicare that covers medical services and supplies
* Medicare coverage that only covers medications
The original Medicare that covers medical services and supplies
In Step Therapy, in order for a step 2 medication to be approved, what must take place?
* One or two step 1 medications must be tried and successful
* One or two step 1 medications must be tried and failed
* Step 1 alternatives are recommended by the pharmacy technician
* Step 1 alternatives are recommended by the prescriber
One or two step 1 medications must be tried and failed
The Centers for Medicare and Medicaid Services (CMS) contracted for the National Committee for Quality Assurance (NCQA) to identify categories of medications that have an increased risk of adverse effects in the elderly population. These medications are called:
* Specialty tier medications
* High-risk medications (HRM)
* Preferred medications
* Brand medications
High-risk medications (HRM)
A Non-Formulary Exception Request can be approved based on the following criteria:
* The provider has documented that the patient has a tolerance to two or more formulary drugs
* The provider has sent in supporting documents indicating that the formulary alternatives were as effective as the requested drug
* The patient was successful at the number of formulary drugs required from the formulary alternative list
* Paid claims for medications tried on the formulary
Paid claims for medications tried on the formulary
Many health plans utilize payer-owned mail-order pharmacies or contracted mail-order pharmacies. What is the downside to mail-order pharmacies?
* Limited mail services leads to the limited reliability of medication services
* Medication is typically delivered in less than 24 hours
* Patients have less of a copay when they utilize the mail-order pharmacy
* Mail-order pharmacies have preferred pricing for the patients
Limited mail services leads to the limited reliability of medication services
Due to a lack of transparency and education about formulary and insurance guidance information, a majority of prior authorization requests are processed:
* At the point of prescribing
* After the pharmacist performs a thorough review
* Retrospectively after a claim is rejected in the pharmacy
* Once the point-of-sale pharmacy processes the prescription
Retrospectively after a claim is rejected in the pharmacy
During the prior authorization process, once all information is gathered, approved or denied, what is the final step in this process?
* Submission of the prior authorization request
* The pharmacist performs a thorough review and may use their clinical judgment at times
* Verification of the contact information for the prescribing physician
* Both, the patient and prescriber, receive a letter of notification that the PA is processed through the insurance company
Both, the patient and prescriber, receive a letter of notification that the PA is processed through the insurance company
During an Opioid Care Coordination Alert an alert will be triggered when the cumulative dose of opioid prescriptions reaches or exceeds which amount?
* 90 MME
* 120 MME
* 200 MME
* 60 MME
90 MME
A preferred drug can be defined as:
* A drug on a specialty tier
* A drug on a higher cost-sharing tier
* A drug on a lower cost-sharing tier
* A drug that meets brand, generic, and biologic standards
A drug on a lower cost-sharing tier
