Process Guide: Keurig Dr Pepper (KDP) Eligibility Discrepancies (GLP-1 Claims Lag)

A guide for handling Keurig Dr Pepper (KDP) members who report active GLP-1 use but appear ineligible (e.g., 'Terminated' or 'Not Found') in B2B due to the Rightway PBM data lag. Covers verification, pre-qualifying questions, and the Jira escalation workflow.

⚠️ Important: This workflow applies only to Keurig Dr Pepper (KDP) members.

The Issue: Missing Eligibility Data

We have identified that some KDP members on a GLP-1 are not appearing in the eligibility file due to the transition to the new PBM, Rightway (effective 1/1).

• The Cause: Rightway only received historical claims data from Jan–Sept 2025. Claims from Oct–Dec 2025 have not yet been loaded.

• The Impact: Members whose first GLP-1 fill occurred between Oct–Dec 2025 may not yet appear as eligible.

• The Fix: These members generally need to either wait for the data load (later this month) or attempt to fill a prescription at a pharmacy (the denial triggers the eligibility file update).

The Workflow

Follow these steps when a KDP member claims eligibility but appears as "Terminated" or "Not Found" in our system.

Step 1: Verify in B2B

Check the member's status in B2B.

• If the member is Terminated or Not Found, proceed to Step 2.

• Note: If they are Active, proceed with standard enrollment.

Step 2: Ask Pre-Qualifying Questions

Since the data is missing, you must verbally confirm the use case to rule out general ineligibility. Ask the following:

1. "Are you currently taking a GLP-1 medication?"

2. "Do you have a diagnosis of Diabetes?"

3. "Are you attempting to fill a new prescription that was denied at the pharmacy?"

   • Context: If they have an outside prescription, attempting to fill it (and getting denied) creates the data point needed to add them to the eligibility file.

4. If the member confirms they are on a GLP-1 or attempting a fill, escalate the case by raising a Jira ticket.

Step 3: Submit a Jira Ticket

1. Open the member’s Zendesk ticket.
2. Click the Apps button → Create issue under JIRA.
3. Select Support Escalations (ESCA) as the project.
   
4. Fill in System Service request for the issue type 
5. Assign the ticket to Jessica Vallerie
6. In the Summary type Keurig Dr Pepper
7. Fill the required fields in the description:

 Copy and paste the template below into the ticket description.

Jira Ticket Template:

Is on GLP1 currently: [YES/NO] 
Is new GLP1 prescription and has been denied at pharmacy: [YES/NO]
Has Diabetes: [YES/NO]
B2B Status: [e.g., showing terminated in B2B]
Member Eligibility UUID: [Insert UUID]
Action: Need to confirm eligibility with AM (KDP/Rightway Claims Lag)

Resolution & Next Steps

1. Do Not Draft Your Own Response: Do not create a new macro or write a manual reply yourself.

• The Dev/Jira team (Jessica) will provide the correct language based on the specific use case (e.g., explaining the claims lag or instructing the member to trigger a denial).

• Send the Provided Response: Once you receive the response text from the Dev team( example below)

  

• Copy & paste the text exactly as provided.
• Send it to the member as a Public Reply.

2. Close the Ticket: After you have submitted the Jira ticket and sent the public reply to the member, you may close the Zendesk support ticket.

   Note: Do not keep tickets open while waiting for the PBM file update 

   • Claims Lag: Once the PBM files update (expected after 1/28/2026), Account Managers will manually check these cases and open new tickets for outreach if the member becomes eligible.

   • New/Denied Rx: This is an ongoing workflow; the denial triggers the data flow, eventually updating their status.