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Frequently Asked Questions |
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How do I initiate the program?
•Your
consent is required to implement the Pharmacy Program.
*
The states of MA, ME, MN, NH, NY, OH, RI do not allow use of a
temporary card and require the
“registered” card
Do
I have to participate?
No, you may choose not to participate in the prescription program
by phoning Hewitt, Coleman’s Managed Care Department at
1-800-638-6829, extension 853.
Is
it necessary for HCA to have the First Report prior to the
claimant receiving medications?
No, as the employer, you will have access to the Temporary Form
Card. This will allow the
claimant to present to a participating pharmacy and have a 7-day
supply of medications on the approved list filled. A First
Report must be filed before the end of the 7-day period in order
for the adjuster to complete their investigation and assign an
Active
status to the claim.
Otherwise, medications will not be dispensed. The Temporary Card
can be downloaded from our web site by participating clients.
Do
you have a 1-800 First Report Service?
Yes. You may choose to
utilize our First Report service and be prompted to issue the
Temporary Form Card. This service can be an effective tool to use
in conjunction with your pharmacy program.
For more information, call our managed care department at
1-800-638-6829, extension 853.
Are
materials available in Spanish?
Yes, materials are available in both English and Spanish.
Who
would the Injured Worker phone with questions?
The Injured Worker should call their adjuster regarding claims
issues. Issues regarding
pharmacy locations, mail order, etc. may be directed to Express
Scripts at 1-800-945-5951.
What is included in the costs of the program?
The percent of savings fee covers the costs of monthly detail
reporting, booklet and card distribution, clinical pharmacist
oversight, pharmacy compounding and dispensing fees, state taxes,
pharmacy utilization and pharmacological management.
What happens if medications are prescribed that are not on
your
approved list?
•For
an Active claim status, the HCA adjuster or nurse will be
contacted by Express Scripts and must respond within 24 hours,
either approving or declining the medication pay.
•Special
claimant profiles can be established to accommodate special needs.
What medications are on the prior approval list?
•Antidepressants:
Serzone, Celexa, Prozac, Paxil, Zoloft
•Narcotic
Analgesics: Duragesic, Oxycontin, Morphine
Prescriptions for these medications will trigger Nurse Triage and
Case Management review.
What happens if a medication needs prior approval on a
weekend?
•Medications
requiring Prior Approval are limited.
The physician may be contacted to choose an alternate
medication included on the approved list OR the medication may be
approved. This program is intended to service the outpatient
claimant.
Do
physicians receive a list of approved medications?
Per Employer Special Instructions, HCA will issue a listing of the
approved medications.
What type of medical management intervention ensues when
medications not included on the approved list are deemed medically
appropriate?
•The
file is reviewed by the TCM nurse with recommendations regarding
implementation of ongoing medical management.
Is
the Injured Worker balance billed?
No, the pharmacist has contractually agreed to the reduced charge.
Can
a profile for a specific Injured Worker be customized?
Yes, phone your Hewitt, Coleman adjuster or nurse.
If a claimant requires medications typically not prescribed
in association with workers’ compensation, a clinical profile can
be created for the claimant, so medications can be filled with no
out-of-pocket expenses.
What type of Utilization Review is in place?
What happens after the 7 Day Short-Fill?
•The
Adjuster completes the investigation of the claim and assigns a
pharmacy status
•Electronic
pharmacy eligibility status is transmitted daily so that the
pharmacists will have ready access to current data
•All
“Active Status” claimants will receive a booklet and registered
pharmacy card detailing the program elements, along with a list of
the participating pharmacy chains*.
*
In order to locate independent pharmacy members the claimant will
need to phone Express Scripts or the Employer may access the
directory on Hewitt, Coleman’s web site and print it for posting.
What if a claimant loses medication or goes out of town or the
prescription will expire on a holiday?
•Special
handling instructions have been issued to Express Scripts for all
of the above scenarios.
Reasonableness will be employed and adequate medication will be
issued to cover the urgent or unusual circumstance.
How
may a claimant initiate Mail Order?
The HCA adjuster will designate candidacy for mail order.
This status will be transmitted to Express Scripts, who
will in turn contact the claimant directly.
What happens when the claim closes?
The
pharmacy status is changed to “closed” blocking future
prescriptions from being filled.
If I currently utilize another pharmacy arrangement, how do I
change?
•Contractual
constraints will supersede all other considerations.
On an individual basis, pharmacy service can be redirected
where no contractual constraints apply.
HCA can initiate this process.
With a signed Pharmacy Management Agreement, HCA will
assume our client has no other binding contract for pharmacy
management and will redirect all prescriptions through Express
Scripts. The claimant may phone Express Scripts at 1-800-945-5951.
They will need the name of the doctor, phone number, and
the types of medications they are taking.
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