Prescription Review

Question 1

Insurance Rejections

Answer 1

• Most common rejection: “refill too soon”

- Usually the insurance company will give the earliest date that the refill will be covered

Question 2

Steps to take when you receive a rejection

Answer 2

1. When you get a “refill too soon” rejection, you should always look at the date of the previous filled prescription.
2. If the prescription has changed (i.e. frequency, days supply) then you will need to submit an override or call the insurance company.
3. If the patient is going away on vacation then you will need to get a vacation override.

Question 3

Prior Authorizations

Answer 3

• PA requires that the physician obtain approval from the prescription insurance company
• PA helps to minimize costs, wherein benefits are only paid if the medical care has been pre-approved by the insurance company
• Without a PA, the insurance company will not pay for the medication
• May only be valid for a limited time, such as a for 1 month up to one year (after need to restart)

Question 4

At a minimum, a pharmacy staff member needs the following information from the patient’s new card:

Answer 4

• Name of primary account holder
• Rx ID Number
• Rx Group Number
• BIN number

Question 5

Pharmacy Benefit Managers (PBMs)

Answer 5

• Responsible for developing and maintaining drug formularies, contracting with pharmacies, negotiating discounts and rebates with drug manufacturers, and processing and paying prescription drug claims.

Question 6

Lower Premium

Answer 6

HIGHER cost when you get care / copay, deductible, coinsurance
- good for person who doesn’t plan to need a lot of health care services

Question 7

Higher Premium

Answer 7

LOWER cost when you get care / copay, deductible, coinsurance
- good for person who plans to use a lot of health care services

Question 8

DUR is classified in three categories:

Answer 8

• Prospective: evaluation of a patient’s drug therapy before medication is dispensed
• Concurrent: ongoing monitoring of drug therapy during the course of treatment
• Retrospective: review of drug therapy after the patient has received the medication

Question 9

DUR PROFESSIONAL SERVICE CODE

Answer 9

• defines the pharmacist’s intervention when a conflict code has been identified

M0 - Prescriber consulted
PE - Patient education
P0 - Patient consulted
R0 - Pharmacist consulted other source

Question 10

Treatment Authorization Request (TAR)

Answer 10

• In order to request drug(s) that are not covered, pharmacists have to fill out an electronic TAR and submit to Medi-Cal
• The patient need more than 6 prescriptions in one month
• The prescription drug is not on Medi-Cal’s approved formulary list
• The prescription drug comes in a different formulation than the one on Medi-Cal’s approved list

Question 11

Patient Assistance Program

Answer 11

• PAPs help people with no health insurance and those who are underinsured afford medications
• These programs are managed by pharmaceutical companies, nonprofits, and government agencies. PAPs may cover the full cost of medications or provide a discount.

Question 12

Drug Discount Cards

Answer 12

You can use the card instead of insurance if

• A drug isn’t covered by your insurance
• Your insurance has no drug coverage
• You have a high drug deductible
• The card offers a better price than your copay
• You are in the Medicare Part D donut hole

Question 13

CURES

Answer 13

• Database of Schedule II, III and IV controlled substance prescriptions dispensed
• Access information regarding patient’s controlled substance history
• To assist law enforcement and regulatory agencies in prevention and diversion of control substance abuse
• Each pharmacy will provide information to the department of Justice on a weekly basis