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Official Course
Description: MCCCD Approval:
4-27-04 |
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CSR138
2004 Spring – 2009 Summer I |
L+L |
3.0 Credit(s) |
4.0 Period(s) |
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Pharmacy
Benefit Service Provision |
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Pharmacy
benefits management company plan member service provision concerns. Emphasis
on ensuring accurate mail order pharmacy service. Covers drug inquiry and
identification operations, network participant pharmacy location, and plan
benefit explication issues. Prerequisites: None. |
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Go to Competencies Go to Outline
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MCCCD
Official Course Competencies: |
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CSR138 2004
Spring – 2009 Summer I |
Pharmacy Benefit Service Provision |
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1.
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Locate specific pharmacy benefit management company plan
information. (I) |
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2.
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Review plan summary information in preparing responses to
specific member questions. (II) |
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3.
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Differentiate between in-network and out-of-network claim
coverage. (III) |
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4.
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Match National Drug Code (NDC) and drug identification
information. (IV) |
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5.
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Identify the classes to which a particular drug belongs.
(V) |
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6.
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Provide mail order drug price estimates to inquiring plan
members. (VI) |
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7.
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Perform drug inquiry operations. (VII) |
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8.
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Locate pharmacies at which plan members may most
inexpensively fill prescriptions. (VIII) |
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9.
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Use age appropriate communication strategies in serving
elderly plan members. (IX) |
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10.
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Demonstrate the ability to perform mail order prescription
services to plan members. (X) |
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11.
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Arrange for over the phone credit card payment for
prescriptions. (XI) |
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12.
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Resolve mail order prescription processing issues. (XII) |
Go to Description Go to top of
Competencies
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MCCCD
Official Course Outline: |
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CSR138 2004
Spring – 2009 Summer I |
Pharmacy Benefit Service Provision |
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I. Plan Information
Location A. Member Plan
Identification 1. Customer Reported Plan
Membership 2. Customer Plan
Identification B. Specific Plan Database
Navigation C. Individual Plan
Information Identification 1. General Plan Benefits 2. Plan Exception
Information II. Plan Summary Review
Concerns A. Summary Screen
Navigation B. Field Location C. Plan Information
Interpretation III. Network Claim Coverage
Differentiation A. Paper Claim Summary
Review 1. Inter-Network Claims 2. Out-Of-Network Claims B. Filing Deadlines C. Claim Preparation IV. National Drug Code
(NDC) Concerns A. Manufacturer
Identification B. Product C. Package Size D. Code-to-Product
Identification E. Product-to-Code
Identification V. Drug Classification
Identification A. Drug Inquiry Definitions
B. Federal Schedules C. Federal Legend
Designation D. Injectable
Drug Issues E. Covered Over-The-Counter
Drugs F. State Controlled Drugs VI. Mail Order Estimate
Provision A. Provision Restrictions B. Medicine Quantification
Concerns C. Drug Strength
Identification D. Quote Provision VII. Drug Inquiry
Operations A. Purpose B. Database Navigation C. Specific Drug Estimate
Provision VIII. Pharmacy Location A. Network Participation B. Specific Pharmacy
Location IX. Age Based Communication
Strategies A. Age Typology 1. Elderly 2. Veterans 3. Baby Boom Generation B. Expectation
Identification C. Tailored Communication
Strategies X. Mail Order Prescription
Provision A. Benefit Identification B. Mail Order Service
Initiation C. Refill Services D. Addressing Concerns XI. Charge By Phone Payment
A. Individual Payment
Processing B. Credit File Creation C. Credit Balance Inquiry
Performance XII. Mail Order Issue
Resolution A. Order Status
Identification B. Issue Identification C. Issue Escalation D. Documentation |
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