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Official Course
Description: MCCCD Approval: 4-27-04 |
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CSR136 2004
Spring – 2009 Summer I |
L+L |
3.0 Credit(s) |
4.0 Period(s) |
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Pharmacy Benefit Member Service |
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Pharmacy benefit member service operations. Emphasis on providing benefit to plan explanations to plan members. Covers co-payment and plan exception information. Includes generic and name brand plan coverage and substitution explanation information. Prerequisites: None. |
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Go to Competencies Go to Outline
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MCCCD Official Course Competencies: |
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CSR136 2004 Spring – 2009 Summer I |
Pharmacy Benefit Member
Service |
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1. |
Explain prescription plan benefits to inquiring members. (I) |
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2. |
Identify applicable pharmacy benefit management company payment level formulas. (II) |
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3. |
Relate payout threshold stipulations to inquiring plan members. (III) |
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4. |
Cite restrictions on sharing company information with members. (IV) |
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5. |
Describe carrier arrangements that may affect payment to individual members. (V) |
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6. |
Identify coverage restrictions associated with brand name and generic medicine substitutions. (VI) |
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7. |
Arrange for the processing of insulin and syringe orders. (VII) |
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8. |
Describe how prescription benefits are offered in a managed care system. (VIII) |
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9. |
Explain mail order medication co-payment information. (IX) |
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10. |
Determine if a particular type of medication is covered as an exception to general plan stipulations. (X) |
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11. |
Relate plan exceptions to inquiring plan members. (XI) |
Go to Description Go to top of
Competencies
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MCCCD Official Course Outline: |
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CSR136 2004 Spring – 2009 Summer I |
Pharmacy Benefit Member
Service |
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I. Benefit Plan Elements A. Co-Pay B. Advance Supply Limitations C. Deductible Issues D. Authorization E. Override Stipulations F. Maximum Payment Ceilings 1. Benefit Ceiling 2. Customer Cost Ceiling II. Formula Review A. Formula View Navigation B. Code Entry C. Formulary Number Issues D. Payment Level 1. Identification 2. Detail Review III. Payout Threshold Stipulations A. Accumulation Limit Information B. Co-Pay Issues 1. Exceptions 2. Typology C. Tier Co-Pay Concerns D. Plan Audit Review IV. Desk Instruction Usage A. Instruction Review B. Information Sharing Stipulations V. Carrier Agreement Concerns A. Missing Medicine Replacement B. Vacation Supply Policy C. Pass-Thru Plan Reimbursement Issues VI. Generic/Brand Name Medicine Substitution A. Dispense as Written Code Interpretation B. Maximum Allowable Cost 1. Penalty 2. Explanation Scripts C. Generic Co-Pay for Brand Name Medicine Programs 1. Typology 2. Stipulations VII. Insulin/Syringe Order Processing A. Plan Options B. Plan Option Qualification Criteria VIII. Managed Indemnity Program A. Plan Types B. Drug Class Issues C. Maintenance Drug Identification IX. Mail Order Co-Pay Issues A. Information Location B. Co-Pay Amount C. Co-Pay Exceptions X. Plan Exceptions A. Plan Coverage Status B. Exception Codes C. Quantity Concerns D. Maintenance Medications XI. Plan Exception Explanation A. Age Restriction Issues B. Drug Exception Detail Location C. Explanation Concerns |
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