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Center for Curriculum and Transfer Articulation
Prior Authorization Programs and Systems
Course: CSR144

First Term: 2021 Spring
 Lecture   2.0 Credit(s)   2.0 Period(s)   2.0 Load  
Subject Type: Occupational
Load Formula: S- Standard


Description: Prior authorization programs and systems for federal employees. Covers Med-Ex, `Buy and Bill` and Medical Formulary Exception (MFE) programs as well as identification and processes for compounds. Also covers the Clinical Authorization System (CAS) program organization and use, including clinical rationales, outcomes, inquiries, and non-covered Qsets.



MCCCD Official Course Competencies
1. Explain the Med-Ex program. (I)
2. Explain the `Buy and Bill` process. (I)
3. Review Medical PA eligibility. (I)
4. Describe the process for Managed Formulary Exception (MFE). (I)
5. Compare and contrast compound characteristics. (II)
6. Describe Clinical Authorization System (CAS) organization. (III)
7. Differentiate between various types of outcomes. (III)
8. Explain various non-covered guidelines and processes. (III)
9. Review procedures for processing medication requests for military members. (IV)
MCCCD Official Course Competencies must be coordinated with the content outline so that each major point in the outline serves one or more competencies. MCCCD faculty retains authority in determining the pedagogical approach, methodology, content sequencing, and assessment metrics for student work. Please see individual course syllabi for additional information, including specific course requirements.
 
MCCCD Official Course Outline
I. Programs and processes
   A. Med-Ex
      1. Definition
      2. Medications
      3. Processes
      4. Communications
   B. Buy and bill
      1. Definition
      2. Process
      3. Limitation
   C. Medical Prior Authorization
      1. Definition
      2. Eligibility
      3. Procedures
   D. Managed Formulary Exception (MFE)
      1. Definition
      2. Eligibility
      3. Process
II. Compounds
   A. Identification
      1. Single
      2. Multiple
      3. High dollar
   B. Processes
III. Clinical Authorization System (CAS)
   A. Organization
      1. Member information
      2. Contact information
      3. Call notes
      4. Eligibility/history
      5. Taskbar
   B. Guidelines
   C. Tabs
   D. Clinical rationale
   E. Outcomes/close options
      1. Definition
      2. Restrictions
      3. Types
      4. Procedures
      5. Customer service unit
      6. Overrides
   F. Pend to pharmacist
   G. Inquiries
   H. Not covered Qset
      1. Types
      2. Guidelines
      3. Processes
      4. Notations
IV. Military requests
   A. Addresses
   B. Procedures
 
MCCCD Governing Board Approval Date: November 24, 2020

All information published is subject to change without notice. Every effort has been made to ensure the accuracy of information presented, but based on the dynamic nature of the curricular process, course and program information is subject to change in order to reflect the most current information available.