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Center for Curriculum and Transfer Articulation
Pharmacy Prescription Benefit Plans
Course: CSR155

First Term: 2024 Fall
 Lecture   3.0 Credit(s)   3.0 Period(s)   3.0 Load  
Subject Type: Occupational
Load Formula: S - Standard Load


Description: Overview of pharmacy prescription benefit plans. Includes types of plans, limitations, and drug coverage in addition to fulfillment requests. Also covers procedures for accessing accounts, responding to caller inquiries, completing test claims, and steps for locating formulary alternatives.



MCCCD Official Course Competencies
1. Explain procedures for responding to caller inquiries and for accessing customer accounts. (I)
2. Access and update member eligibility information. (I)
3. Use Health Insurance Portability and Accountability Act (HIPAA) related documents. (I)
4. Describe types of benefit plans, their drug coverage and plan limitations. (II)
5. Identify group codes. (II)
6. Identify eligibility situations requiring senior team resolution. (II, III)
7. Identify opportunities for alternate resolution of fulfillment requests. (III)
8. Describe reasons for paper claims. (IV)
9. Describe the importance of a test claim. (IV)
10. Complete an accurate test claim. (IV)
11. Describe steps to locate a formulary alternative. (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. Pharmacy prescription benefits and plans
   A. Description
   B. Organization
   C. Services
   D. Advantages
   E. Representative responsibilities
      1. Calls
      2. Member questions
      3. Customer service
      4. Types of callers
      5. Account access
      6. Documentation
   F. Confidentiality and integrity
      1. Purpose
      2. Importance
      3. Customer information
      4. Health Information Portability and Accountability Act (HIPAA)
      5. Documents
   G. Eligibility
      1. Types
      2. Status
      3. Procedures
   H. Inquiries
      1. Types
      2. Procedures
II. Plan design
   A. Types of plans
      1. Standard
      2. Basic
      3. Basic consumer
   B. Copay structures
   C. Drug coverage
   D. Benefits
      1. Retail
      2. Mail
   E. Plan limitations
   F. Overrides
   G. Pharmacy networks
   H. Catastrophic benefits
   I. Accumulations
   J. Exceptions
   K. Eligibility
      1. Types
      2. Status
      3. Restrictions
      4. Issues
      5. Resolution
   L. Group codes
III. Fulfillment calls
   A. Definition
   B. Types
   C. Resolution manager
   D. Delivery methods
   E. Statement of cost
IV. Test claim
   A. Definition
   B. Work instructions
      1. Codes
      2. Fields
      3. Screens
   C. Results
      1. Types
      2. Interpretation
   D. Alerts
   E. Drugs
      1. Classifications
      2. Plan designs
      3. Alternative medications
      4. Specialty meds
   F. Paper claims
      1. Use
      2. Restrictions
      3. Refunds
 
MCCCD Governing Board Approval Date: June 25, 2024

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.