Intake and Patient Onboarding Flashcards

A specialty pharmacy receives an e-prescription for a limited distribution drug (LDD) that the pharmacy is not in the manufacturer's network to dispense. What is the most appropriate intake action?

Answer: Transfer the prescription to an in-network specialty pharmacy and notify the prescriber and patient

LDDs can only be dispensed by pharmacies in the manufacturer's network, so prompt transfer with notification prevents delays in therapy.

During a benefits investigation, the intake team learns a self-administered specialty drug is covered under the patient's medical benefit rather than the pharmacy benefit. What does this primarily affect?

Answer: How the claim is billed and which authorization process applies

Medical versus pharmacy benefit coverage determines the billing pathway (e.g., J-code/CMS-1500 vs. NCPDP) and the payer's prior authorization requirements.

A commercially insured patient cannot afford a $3,000 specialty copay. Which resource is typically the first option to check for this patient?

Answer: Manufacturer copay assistance card

Manufacturer copay cards are generally available to commercially insured patients and can sharply reduce out-of-pocket costs.

Why are manufacturer copay coupons generally prohibited for patients enrolled in Medicare Part D?

Answer: They may violate the federal Anti-Kickback Statute

The OIG considers manufacturer copay assistance for federal health program beneficiaries a potential inducement under the Anti-Kickback Statute.

Which item is typically NOT required on a complete specialty pharmacy referral intake form?

Answer: The patient's preferred grocery store

A complete referral needs clinical, prescriber, and insurance data, but unrelated personal preferences are not required.

A prior authorization for a specialty drug is denied for 'step therapy not met.' What is the most appropriate next intake step?

Answer: Work with the prescriber to document prior failed therapies or submit a step-therapy exception

Step-therapy denials can often be overturned with documentation of previous trials, contraindications, or an exception request.

During the patient welcome call, which topic is most essential to cover before the first shipment?

Answer: Confirming delivery address, date, and someone available to receive cold-chain shipments

Confirming delivery logistics prevents lost or temperature-compromised shipments of high-cost medications.