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Pharmskills Online - REJECTED - Third Party Insurance Prescriptions


 
Electronic Rx - eRx #: 70893, Date: July 1, 2026
Hilda R. Morgan
Lovaza 1 g Softgel Capsule
Dispense: 120
Sig: 2 po BID to reduce hypertriglyceridemia
Prescriber: Carolyn Abman
DAW: give generic
          

 
Error Type:      
 
Documentation:
 

Electronic Rx - eRx #: 72612, Date: July 1, 2026
Charles O. Elder
Strattera 40 mg Capsule
Dispense: 30
Sig: 1 po QD for ADHD
Prescriber: Harold L. Green
DAW: substitution permitted
          

 
Error Type:      
 
Documentation:
 

Electronic Rx - eRx #: 20461, Date: July 1, 2026
Edward M. Miller
Zyvox 600mg Tablet
Dispense: 28
Sig: 1 po BID x14 days for vancomycin-resistant enterococci (VRE)
Prescriber: Samuel Bernstein
DAW: generic okay
          

 
Error Type:      
 
Documentation:
 

Electronic Rx - eRx #: 10663, Date: July 1, 2026
Margaret Morgan
Pristiq 50 mg ER Tablet
Dispense: 30
Sig: 1 po QD for the treatment of major depression
Prescriber: Norman Keyes
DAW: substitution permitted
          

 
Error Type:      
 
Documentation:
 

CLICK HERE to view the Medicare Part D plan's drug formulary

 

 
INSTRUCTIONS
 
Pharmacists are confronting many challenges with the Medicare Part D Prescription Drug Benefit. Among the most time consuming are formulary management, prior authorization requirements, step therapy protocols, and tight formularies. Most Medicare beneficiaries will encounter new formulary requirements, so preparation will be key for pharmacists during their patient's transition to Medicare Part D when they will be in the crucial position of interacting between the plan, prescriber, and patient to lessen any delays in drug coverage.
 
This exercise will test your ability to help patient's identify which medications may need to be adjusted in order to comply with their plan's formulary. Each patient has a prescription which falls into one of three different problem categories: 1) non-optimal tier, 2) drug requiring a PA, and 3) drug requiring step therapy. You must identify the problem associated with each prescription and then give appropriate documentation, as described below.
 
Problem #1 - Tier Problem
Pharmacists should strive to ensure that their patients are using the most cost-effective drug alternative. The patient's copay amount for a prescriptions depends on the medication's tier. Most plans have five tiers:
Tier 1 - Preferred Generic Tier
  • The Generic tier is the lowest-cost tier.
Tier 2 - Generic Tier
  • The Generic tier is a low-cost tier and contains many generic drugs.
Tier 3 - Preferred Brand Tier
  • This is a middle-cost tier, and includes preferred brand drugs and certain higher-cost generic drugs.
Tier 4 - Non-preferred Tier
  • This is a higher-cost tier and includes non-preferred brand drugs and certain higher-cost generic drugs.
Tier 5 - Specialty Tier
  • The specialty tier is the highest-cost tier. A specialty tier drug is a very high cost or unique prescription drug, which may be brand or generic.

Identify prescriptions where the problem is that the prescribed drug is a tier 3-5 drug. This usually means there is a preferred-generic (tier 1) or generic drug (tier 2) alternative. Document a drug alternative that would be in a lower tier and thus save the patient money.

Problem #2 - PA Problem
Prior Authorization (PA) is also known as "pre-certification." Medications restricted by the plans in this way will require the beneficiary's physician to contact the plan to request coverage of the medication. The physician will usually have to provide the plan with documentation for why this medication is needed for the beneficiary. Typical reasons for requesting a PA drug and the required documentation include:
  • Alternate drug(s) contraindicated or previously tried, but with adverse outcome (eg, toxicity, allergy, or therapeutic failure)
    • Specify: (1) Drug(s) contraindicated or tried; (2) adverse outcome for each; (3) if therapeutic failure, length of therapy on each drug(s)
  • Complex patient with one or more chronic conditions (including, for example, psychiatric condition, diabetes) is stable on current drug(s); high risk of significant adverse clinical outcome with medication change
    • Specify: Anticipated significant adverse clinical outcome
  • Medical need for different dosage form and/or higher dosage
    • Specify: (1) Dosage form(s) and/or dosage(s) tried; (2) explain medical reason
  • Request for formulary tier exception
    • Specify: (1) Formulary or preferred drugs contraindicated or tried and failed, or tried and not as effective as requested drug; (2) if therapeutic failure, length of therapy on each drug and adverse outcome; (3) if not as effective, length of therapy on each drug and outcome

Identify prescriptions where the problem is that it is a PA drug. Document what is required by the plan before the physician is allowed to prescribe this drug.

Problem #3 - ST Problem
Step therapy (ST) is a variation of prior authorization. With this utilization management technique, the plan requires the physician to use a preferred drug for that condition, before being allowed to use a different drug.

Identify prescriptions where the problem is that it is a ST drug. Document which drugs or drug classes the plan expects the physician to have tried in this patient before prescribing this drug.