This article details the streamlined process for escalating complex prescribing issues that require direct action from the Prescribing Support Group (PSG Tier 1). All escalations follow a mandatory process: gather unique issue information, complete the internal escalation template, set the ticket to 'On-Hold,' and notify the member. The guide covers Prior Authorization (PA) denials, change pharmacy requests, medication adjustments, and handling GLP-1 clinical pushback, ensuring agents gather all required information.
| Category | Agent Talking Points |
|---|---|
| Change Pharmacy | "I can certainly help you submit a request to change your pharmacy, but for a fast fix, you can often call your current pharmacy to have them transfer the prescription to a different location." |
| Prior Authorization | "I need to gather details about your insurance and the denial message you received so I can create the complete the request to handle the Prior Authorization process." |
| Final Escalation Step | "I'm sending this to our prescribing support group. You will hear back from them within 24-72 during business days either via chat in the app or by email once the request has been updated." |
Table of Contents
Prescribing Escalation Flow - MANDATORY STEPS
Prior Authorization (PA) Request
Side Effects Questions or Concerns
GLP-1/Clinical Pushback (Pharmacy/Insurance)
PA Rejections (If a Doctor’s Office/ Pharmacy Calls Support)
Prescribing Escalation Flow - MANDATORY STEPS
Use this flow when ANY issue requires a clinical review by the Prescribing Support Group.
- Find the Prescriber: Search Admin to find the member's assigned Prescriber Name and Prescriber Team Code (TC). (Go to Programs > Program Instances, click the team code for AMS.)
- Gather Unique Information: Collect the specific details required for the member's issue (see the "Escalation Issues" section below).
-
Create Internal Note: Use the Prescribing Support:: Prescribing Escalation Template macro and include all unique issue information, plus the following mandatory fields:
- Team Code:
- Prescriber Name:
- Member's pay-org:
- Associated Program:
- Member's state:
- Context of the request: (State the specific issue: PA, Pharmacy Change, Side Effect, etc.).
-
Set Member Expectation & Final Action:
- Inform the member using the "Final Escalation Step" talking point above.
- Send macro: "Support Ticket Escalated to Internal Prescribing Team" to the member.
- Assign the ticket to PSG Tier 1.
- Submit the ticket as Open.
Issues Requiring Escalation to PSG Tier 1
1. Change Pharmacy Request
- Escalation Trigger: Member is unable to transfer the prescription OR requests a change to their default pharmacy.
- Offer Self-Service First: Advise the member they can often call their current pharmacy to transfer the prescription within the same network.
-
Required Unique Info:
- Current location of prescription
- Medication and dosage
- New pharmacy information (Name, Address, Phone number)
- Follow Mandatory Prescribing Escalation Flow above
2. Prior Authorization (PA) Request
- Escalation Trigger: A member, pharmacist, or provider calls about a PA being required to fill a prescription. (Your role is to confirm details, not disclose private health/plan info.)
-
Required Unique Info:
- Which prescription/medication the PA is required for.
- Was the prescription written by a VMP (Vida Medical Provider) or by a non-Vida provider?
- Medication Information: Name, dosage, and date prescribed.
- Follow Mandatory Prescribing Escalation Flow above
3. Adjust Prescription Request
- Escalation Trigger: A member states their pharmacist needs the prescriber to adjust the prescription.
-
Required Unique Info:
- Pharmacy Information: Name, Phone number, and address.
- Medication Information: Medication name and current dosage.
- Request Details: Collect the specific adjustment requested by the pharmacist, as provided by the member.
- Advise patients to inform their pharmacy to contact us directly if patient/pharmacy doesn't hear back within 48-72 hours.
- Follow Mandatory Prescribing Escalation Flow above
4. Side Effects Questions or Concerns
WE ARE NOT IN A POSITION TO ADDRESS SIDE EFFECTS
- Escalation Trigger: Member asks about side effects, needs to speak to their VMP immediately, or is asking to stop medication. Advise them to speak with their provider before stopping medication. If it is an emergency advise that they get emergency care with an in person doctor.
- Action: Follow all Crisis Protocols if applicable. QUICK GUIDE FOR CRISIS PROTOCOL Gather and note details regarding questions or effects from the member. Remind the member they can also chat with their prescriber in the app directly.
- Final Action: Fill in the prescribing escalation template macro adding the details gathered into the context of request, follow the Mandatory Prescribing Escalation Flow mark the request as urgent and assign to PSG Tier 1.
5. GLP-1/Clinical Pushback (Pharmacy/Insurance)
- Escalation Trigger: A member or pharmacy calls support with an issue (e.g., GLP-1 medication is not covered).
-
Escalation Action: Escalate to PSG Tier 1 using the mandatory template to confirm if there is a clinical issue.
- Follow-up: If PSG finds no clinical issue and reassigns the ticket back to Support, follow the process to escalate to the Account Management (AM) team.
- Follow Mandatory Prescribing Escalation Flow above
PA Rejections (If a Doctor’s Office/ Pharmacy Calls Support)
When a provider or clinic calls about a member's Prior Authorization (PA) rejection, your primary role is to gather all required information before determining the next step not to provide an approval or denial reason..
Step 1: Collect Necessary Information (To be included in the internal note)
- Member's full name and Date of Birth (DOB).
- The rejection message received from the pharmacy/PBM.
- The prescribed medication.
- The name of the doctor's office and the name of the person you spoke with.
- The organization (org) and what they require regarding Vida enrollment.
Step 2: Determine Enrollment Status and Action
Use the information gathered above to decide the next step:
1. If the Member Still Needs to Enroll:
- Action: Advise the doctor's office that the member must contact Vida directly to complete their enrollment.
- Ticket Status: Leave an internal note summarizing the call and mark the ticket as Solved.
2. If the Member is Already Enrolled:
- Condition: This applies if the member is already enrolled but in the wrong program.
- Action: Create a new ticket in ZD and reach out to the member to advise, once they reach back out follow process for program change
- Condition: This applies if the member is enrolled in the correct program and claims have been submitted.
- Action: Escalate to Tier 2 to coordinate an Account Manager (AM) review.
- Ticket Status: Leave an internal note summarizing the call and mark the ticket as Open. (Tier 2 will take over, reach out to the AM, and set the ticket to Hold while awaiting a response.)
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