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Center for Curriculum and Transfer Articulation
Retail Pharmacy Plans
Course: CSR155

First Term: 2014 Spring
 Lecture   3.0 Credit(s)   3.0 Period(s)   3.0 Load  
Subject Type: Occupational
Load Formula: S- Standard


Description: Retail pharmacy benefit plan design. Includes types of plans, limitations and drug coverage in addition to fulfillment requests. Also covers procedures for completing test claims and steps for locating formulary alternatives.



MCCCD Official Course Competencies
1. Compare and contrast benefit plans. (I)
2. Determine drug coverage. (I)
3. Determine plan limitations. (I)
4. Differentiate between retail and mail benefits. (I)
5. Describe various benefit plans. (I)
6. Differentiate between types of overrides. (I)
7. Identify group codes. (I)
8. Identify eligibility situations requiring senior team resolution. (I, II)
9. Identify opportunities for alternate resolution of fulfillment requests. (II)
10. Identify claim exceptions. (III)
11. Describe reasons for paper claims. (III)
12. Describe the importance of a test claim. (III)
13. Explain rules to reverse a claim. (III)
14. Complete an accurate test claim. (III)
15. Describe steps to locate a formulary alternative. (III)
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. 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
II. Fulfillment Calls
   A. Definition
   B. Types
   C. Resolution Manager
   D. Delivery Methods
   E. Statement of Cost
III. 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: November 26, 2013

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.