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Must use member's Last Name throughout the call. Example: Mr/Mrs Jones, can you provide me with your member ID? (Can use first name if member requests)If you are speaking to a Ron Jones, address as Mr Jones. Do not address as Mr Ron. The first name may be used upon member request. |
If you are going to present a plan, Go to “Unsure of Plan/Switch Plan”
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Name of Rx (Example: Lisinopril or Lisinopril/HCTZ)
Dosage Type (Example: Capsule or Tablet, 5mg or 10 mg)
Quantity Leave quantity (Example: 30/60/90…It is recommended to use 30 days90)
Frequency (Example: per month, etc) - Leave as one month by default unless there is a reason for another selection.
If there is a generic option, you MUST ask the following:
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| Note |
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IMPORTANT: You must ALWAYS offer to look up medications for the recording |
Pharmacy
Verify Must verify the member's pharmacy:
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Part Skip the part B buy-down selection under “Other Preferences” is optional unless requested by the member asks for it:
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Plan name and premium [Extra Help/Medicaid: Should be quoted from the LIS table and original premium of the plan]
Medical deductible
PCP & Specialist Copays
ER and inpatient hospital copays
Dental, Vision, and Hearing (if applicable)
Identify 1 PCP and at least offer to look up Specialist and Hospital networks
Pharmacy Deductible [Extra Help/Medicaid: Should be quoted from the LIS table and original deductible of the plan]
List at least 1 Preferred Pharmacy. If you originally selected a Standard Pharmacy click the “Pharmacy Directory” link to find a Preferred Pharmacy:
State that the mail order pharmacy is CVS Caremark
OPTION 1: Prescription Copays
State copays applicable to member’s drugs [Example: “Your Metformin is a tier 1 Rx with a $__ copay. Your Eliquis is a tier 3 Rx with __% Coinsurance.”
State copay amounts for each tier [Example: Tier 1 drugs have a $___ copay; Tier 2 drugs have a $ __ copay; etc] This must be stated when members say they do not currently have any prescriptions.
State whether each tier applies to the deductible [Example: The deductible for this plan applies to tiers 3, 4, and 5. Some of your drugs are tier 3, so the deductible will apply to those drugs”]
OPTION 2: Prescription copays/coinsurances for each tier.
Tier 1 are your preferred generics which have a $__copay. The deductible does/does not apply. The following drugs are tier 1: [name all applicable medications and costs].
Tier 2 are your generics which have a $__copay. The deductible does/does not apply. The following drugs are tier 2: [name all applicable medications and costs].
Tier 3 are your preferred brand name drugs which have a __% coinsurance. The deductible does/does not apply. The following drugs are tier 3: [name all applicable medications and costs].
Tier 4 are your non-preferred brand name drugs which have a __% coinsurance. The deductible does/does not apply. The following drugs are tier 4: [name all applicable medications and costs].
Tier 5 are your specialty drugs which have a __% coinsurance. The deductible does/does not apply. The following drugs are tier 5: [name all applicable medications and costsRestate the name of the medication.
State the tier of the medication.
State whether the deductible applies to the medication.
Quote the copay/coinsurance for each applicable phase of the drug.
[Example: Eliquis is a tier 3 drug. The deductible will apply to this medication. Under the deducible phase, you will pay $__ (if applicable). Then, you will move to the initial coverage phase and will pay $__ (required). Next, you are projected to into what is called the Coverage Gap phase at which point your copay will be $__ (if applicable). Lastly, you are projected to into what is called the Catastrophic Coverage phase at which point your copay will be $__ (if applicable)].
for each drug. You MUST state each of the following items:
| Note |
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You must ALWAYS state pricing per tier, even if the member currently has no prescriptions. |
| Note |
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You MUST quote preferred pharmacy pricing. If the member would like to use standard or mail order pharmacies, you may quote that as well. |
12. Quote drug phases that are projected to apply to the caller. To Identify copays for the various phases (Coverage gap/Catastrophic coverage) the agent should go to the Total Costs Tab at the top.
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1311. State applicable drug restrictions for each medication [ie: Quantity Limits, Step Therapy, and Physician Authorization]
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Plan name and premium [Extra Help/Medicaid: Should be quoted from the LIS table and original premium of the plan]
Pharmacy Deductible [Extra Help/Medicaid: Should be quoted from the LIS table]
List at least 1 Preferred Pharmacy. If you originally selected a Standard Pharmacy click the Pharmacy Directory link to find a Preferred Pharmacy:
State that the mail order pharmacy is CVS Caremark
Prescription Copays
State copays for each tier [Example: Tier 1 drugs have a $___ copay; Tier 2 drugs have a $ __ copay; etc] This must be stated regardless of whether the member currently has any prescriptionsfor each drug. You MUST state each of the following items:
Restate the name of the medication.
State the tier of the medication.
State whether the tier deductible applies to the deductible medication.
Quote the copay/coinsurance for each applicable phase of the drug.
[Example: Eliquis is a tier 3 drug. The deductible for this plan applies to tiers 3, 4, and 5. Some of your drugs are tier 3 so the deductible will apply to those drugs”]Quote drug phases that are projected to apply to the caller (To Identify copays for the various phases (Coverage gap/Catastrophic coverage) the caller will go to the Total Costs Tab at the top)
will apply to this medication. Under the deducible phase, you will pay $__ (if applicable). Then, you will move to the initial coverage phase and will pay $__ (required). Next, you are projected to into what is called the Coverage Gap phase at which point your copay will be $__ (if applicable). Lastly, you are projected to into what is called the Catastrophic Coverage phase at which point your copay will be $__ (if applicable)].
| Note |
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You must ALWAYS state pricing per tier, even if the member currently has no prescriptions. |
| Note |
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You MUST quote preferred pharmacy pricing. If the member would like to use standard or mail order pharmacies, you may quote that as well. |
6. State applicable drug restrictions for each medication [ie: Quantity Limits, Step Therapy, and Physician Authorization]
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Closing the Sale
Remember to ask for the sale
If Yes:
Move to Enrollment section - send the quick quote and read the following email disclaimer:
"Providing an email address authorizes us to contact you via email. Your email address will be handled consistent with our Privacy Policy, which you can find on our website at www.aetnamedicare.com”
Inform caller they will get 2 emails (check SPAM folders)
Proceed to the Enrollment Checklist Tab in Contact Center
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Paste the confirmation number
Closing:
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