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Aq.co.yavapai.az.us

Request for Prescription Services (RPS)

1. Client:
Health Services Street: 1090 Commerce Drive 2. Third Party Administrator / Broker:
3. Billing Information:

4. Send Electronic Reports To:
Client TPA / Broker Other No Reports
5. Pharmacy Network:
Other: Safeway & WalMart in Yavapai County 6. Eligibility File Information:
Initial:
Client Specific (additional fee may apply) *834 / 5.2 Layout / Custom Excel file format
Ongoing:
Electronic media eligibility file updates will be sent to Avia Partners 1 Other: Weekly .
If by Avia Partners, client will provide eligibility information via: *Please review Attachment 1 for Manual Member Updates.
*Standard rate: $0.25 per line
Manual Load by Client using Remote Access via Internet Member ID Structure (Member ID, Date of Birth (Month/Day/Year)):
Converted Social Security Number Unique ID Number Format 7. Member ID Cards:
by Avia Partners (includes “Welcome Letter” and plan specific brochure) *Standard rate: $1.00 per card for production and mailing fee.
*Standard rate: $0.25 per card for production fee.
8. Mail Order Benefit:
Mail Order will fill prescription as written, both for quantity and drug. If multi-source drug, generic will be dispensed. 9. Direct Member Reimbursement:
Contact Person Telephone: . Fax: . Contact Mailing Address: . Contact E-Mail: . Avia Partners: DMR Fee: Standard rate: $3.00 per claim Submitted Amount minus Copayment minus DMR fee Plan Reimbursement minus Copayment minus DMR fee If Claim fails plan specific limitations: 10. Coordination of Benefits 3
For Electronic COB, indicate applicable Other Coverage Codes: (check all that apply) 02- Other coverage exists-payment collected 03- Other coverage exists- claim not covered Payer is aware of other coverage existing to which claim should be submitted 04- Other coverage exists-payment not collected. Used in a payable response, when payment is zero with 100% co-payment 08- Copay Billing Only No Electronic COB
11.
Deductible information:
12. Days Supply and Quantity Limitations:
13. Formulary Implementation:
Non-Preferred Products with Non-Preferred Copay Avia Partners Approval, based upon Physician letter Custom Formulary (additional fee may apply) 14. Copay Determination:
Copay for Multi-Source Brands When:
15. Prescriber DEA Format Validation
Standard = Verify that the submitted DEA is in the valid format. This does not ensure that the
Prescriber ID is valid.
Client specific Prescriber list 4

16. Concurrent DUR

Early Refill (75% of supply must be used) Reject to Pharmacy (Standard Rate-$3.00 per instance) Allow Override for Vacation Supplies (Once per year per drug) Allow Override for Lost or Stolen Medication (Not applicable to controlled medications) High Drug Dosage (Greater than 1.25% of maximum approved by FDA) Reject to Pharmacy. With phone call by pharmacy asking for an override, Clinical department will allow override only if current pharmacy literature or manufacturer supports the higher dosage. Clinical department will possibly work with both pharmacy and physician for alternative. (Standard Rate-$30.00 per instance) Non-reject with message to Pharmacy (Both moderate and major interactions) Reject to Pharmacy (Major interactions only). With phone call by pharmacy asking for an override, Clinical department will allow override only if current pharmacy literature or manufacturer allows for the drug interaction. Clinical department will possibly work with both pharmacy and physician for alternative. (Standard Rate-$30.00 per instance) 17. Clinical Intervention and Retrospective DUR

Standard = Avia Partners in partnership with Health Information Designs reviews prescription claim
data to perform Clinical Interventions. Standard rate: $0.30 per claim.
18. Claims Maximum Dollar Limit
Standard = Up to $3000.00 per claim. Help desk will review claim and give authorization if
information is valid. Standard rate: $3. 00 per instance 2
Client Approval = Standard rate: $3.00 per instance 2
19. Drug Inclusions/Exclusions:
Standard = Avia Partners will only give Prior Authorization if Prescriber indicates medically
necessary for 1 year. Standard rate: $3.00 per instance 2
Client Approval = Standard rate: $3.00 per instance 2
Name: .
Phone: . Fax:
Email: Hours of Availability:
Notes: .
Include only
Include only
Category
with Avia
with Client
Partners
Approved
Standard
Prior Auth.
Prior Auth.
Diabetic Supplies (Lancet, Lancet Devices, Alcohol Swabs) Surgical Supply / Medical Device / Ostomy Tretinoin (over 26 years of age) for wrinkles Off Label Use Drugs (Anabolic Steroids, Gender specific drugs for other gender, Provigil, Dostanex, other potential products) Special Exceptions: Not Appplicable . 20. Step Therapy:
Declined
Category
Grandfather
21. Quantity Limits:
Declined
Category
Erectile Dysfunction Drugs (6 doses/month) AntiMigraine Products (3 headaches/month) Cancer AntiEmetics (FDA approved amount) Oral and Nasal Inhalers (FDA approved amount) Nonsedating Antihistamines (FDA approved amount)
22. Client Administrative Fees:

Per claim fee:
ID Card Initial load fee:
ID Card Ongoing load fee:
Eligibility fee:
Prior Authorization fee:
Clinical Prior Authorization fee:
Initial eligibility load:

23. Additional Information:


Client Signature:___________________________ Date:

1 If Client cannot provide ongoing Eligibility files in the Avia Partners file format, a conversion template can be created resulting in an additional fee. 2 Standard Client Approval consists of Avia Partners Help Desk handling members/pharmacy’s requests. Escalations go to the Avia Partners Clinical Pharmacist. Escalations from the Clinical Pharmacist will go to the client for approval. Response is given which is documented, and Avia Partners will return call to member/pharmacy when claim is authorized. 3 In order to allow coordination of benefits, eligibility files and updates must indicate if the member has alternate insurance. Avia Partners will reject claims unless pharmacy sends appropriate COB indicator. 4 Please include DEA number.

Source: http://aq.co.yavapai.az.us/docs/2011/BOS/20111219_402/4803_Avia%20RPS.pdf

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