Transfer Quiz
For PDD plans, do we handle inquiries regarding types of generic substitutions (simple or mandatory)?
Yes
No
If we handle these calls, where in KM can we find this information? Do not use link (example: Medical KM > DRG00 > Admin Guidelines > Steps for determining drug eligibility - PDD and non-PDD plans)
If we do not handle these calls, where should we transfer the call?
Reg_Health
Reg_TBHealth
Ms. Smith is inquiring to change her credit card information where the premiums are automatically being charged from for her PHI plans. What are your next steps? Select all that applies.
- Ask member if plan is individual or group
- Check KM for Policy Specific Info
- Advise the caller to contact BA to update the plan
- Transfer the caller to CSC to update the plan
- Transfer the caller to Individual CCC to update the plan
For PDD plans, if a caller asked about extending the day supply limit because he/she will be travelling out-of-country, can we handle this call?
Yes
No
If we handle this call, where in KM can we find this information? Do not use link (example: Medical KM > DRG00 > Admin Guidelines > Steps for determining drug eligibility - PDD and non-PDD plans)
3. Member at the pharmacy calling because the claim wouldn’t go through, as per checking the plan, you saw this (please refer to the image above). Can you handle the call?
Yes
No
If you can handle, what should you advise?
The drug cannot be submitted through Telus since the plan is Non-PDD
Advise Pharmacist to contact Telus
Claim can be submitted at a later time by the pharmacist
For PDD plans, when asked for compound eligibility, can you handle the call?
Yes
No
If we handle this call, where in KM can we find this information? Do not use link (example: Medical KM > DRG00 > Admin Guidelines > Steps for determining drug eligibility - PDD and non-PDD plans)
If we do not handle this call, where should we transfer the call?
Reg_Health
Reg_TBHealth
For PDD plan, if the result shows MIS00 when doing DIN search, what would be your next step or advise to the caller?
Advise that the drug is not covered.
Call should be transferred Onshore.
Send an F9 inquiry to CCC Tier 3 to determine eligibility.
SCENARIO:
An Ontario resident is inquiring coverage for Gilenya 0.5 mg capsule. Plan is Non-PDD.
You completed a DIP search and saw this result (please refer to image above):
Advise that the member needs to contact OHIP for coverage
Transfer the call Onshore
Proceed to DIN search
SCENARIO:
An Ontario resident is inquiring coverage for Gilenya 0.5 mg capsule. Plan is Non-PDD.
You did a DIN search and the results show that the procedure code is DRX00. You mapped the code and provided the coverage based on information you saw in Siebel.
Now, you need to advise the caller of the information you saw from the screenshot above. What field on Siebel will be important for you to check?
0%
0
0%
0
0%
0
What will you advise the caller in regards to the Provincial Integraton?
Advise member they will receive a letter shortly after they make their first claim advising that they will be given 10 weeks to provide information us - signed PDP form & approval or denial from province.
Advise the member that they must first apply for Provincial coverage before we will consider the DIN/Drug.
Advise the member that coverage for the DIN will not be covered until the decision from the Province is added to the file
Scenario:
Plan is PDD. You are checking coverage using the Drug Look up tool and it shows this result:
What does the information on the Percentage Covered field means?
We will only pay if the member purchased Mar-Atorvastatin.
We will pay the price of Lipitor at 75%.
We will pay the price of Mar-Atorvastatin at 75%.
Scenario:
Plan is PDD. You are checking coverage using the Drug Look up tool and it shows this result:
If the member mentioned that she can't tolerate generic drugs, what should you advise or your next step?
Transfer the call Onshore for handling.
Then we will not cover Lipitor under the plan.
Advise that she will have to obtain a referral from her doctor and sent it to SLF for exception.
All claim calls for drugs should be transferred.
Transfer the call Onshore for handling.
Then we will not cover Lipitor under the plan.
Advise that she will have to obtain a referral from her doctor and sent it to SLF for exception.
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