Prescription Refill Requests

This is the comprehensive guide for agents on the Standard and Urgent Prescription Refill Process. Key workflows prioritize member self-service via the in-app "Medicine Refill Check-In" form and medical provider follow-up. The guide clarifies the distinction between Standard (Amber) and Urgent (Red) refills, detailing the mandatory escalation procedure to PSG Tier 1 for urgent requests. It includes agent quick references for expected timelinesand steps for troubleshooting common pharmacy issues like Prior Authorization (PA) denials and medication unavailability.

Table of Contents

Handling Amber Requests (Standard)

Urgent Prescription Refill Escalation (Red Category)

Escalation Process for Urgent Requests

Agent Quick Reference: Timelines and Talking Points

Zendesk Ticket Prioritization

Medication Not Available at the Pharmacy

Medication Not Covered by Insurance

Standard Prescription Refill Process

For most refills, members should be advised to use the in-app process.

1. Advise the member to complete the 'Medicine Refill Check-In' form in the app.
2. Ask if the member has reached out to their provider in the chat section of the app.
3. Instruct the member to schedule a follow-up session with their medical provider.

Handling Amber Requests (Standard)

If a member support agent receives a standard refill request (not an urgent "Red" medication), they should:

• Attempt to schedule the member with a prescriber as soon as available within 7 days of the requested refill date.
• If no scheduling options are available within that timeframe, escalate the request by assigning it to the Prescribing Support Group( PSG Tier 1).

Urgent Prescription Refill Escalation (Red Category)

Urgent requests require immediate action and a change in the ticket priority.

What is an Urgent (RED) Refill?

Medications that fall into the Urgent (RED) category:

• Topamax / Zonisamide
• Contrave / Bupropion / Naltrexone
• Any medication for a member in the Condition Control Program.

Escalation Process for Urgent Requests

1. This procedure is for escalating urgent refill requests for medications found on the RED Category list.
2. Confirm Eligibility: Confirm the medication is on the RED Category list.
3. Update Ticket Priority: Change the Zendesk ticket priority to Urgent.
4. Assign: Assign the ticket to the Prescribing Support Group (PSG Tier 1).
5. Create Detailed Internal Note: Add a detailed internal note using the Prescribing Support:: Prescribing Escalation Template macro. This note must summarize the issue and include all of the following required fields for the Refill Request context:

• Required Escalation Fields: Advanced Prescribing Team Code, Prescriber Name, Member's pay-org, Associated Program, and Member's state.
• Refill Details: Name of Medication (Flag as Category Red), Date first filled, and Date refill needed by.
• Context: Reason for request (must state it's outside of regular monthly follow-up process) and confirmation that the member has a monthly follow-up scheduled with a VMP (Yes/No).

Agent Quick Reference: Timelines and Talking Points

Provide a clear and concise response to members about how long a refill request takes.

Zendesk Ticket Prioritization

Changing the ticket priority helps the prescribing team triage urgent items.

Set the priority to "Urgent" for any of these scenarios:

• Member needs an urgent refill for a Red-level medication.
• Member is experiencing severe side effects and needs to escalate to a VMP.
• An Account Manager (AM) escalates an issue that requires urgent action from the Prescribing team.

Common Prescription Issues & Solutions

These are step-by-step guides for handling common issues members face at the pharmacy.

Medication Not Available at the Pharmacy

This issue often requires a change in pharmacy or an alternative medication.

1. Ask the member: "Did the pharmacy say they're out of stock, or that the medication is simply unavailable there?"
2. If the pharmacy is out of stock, suggest the member call other nearby pharmacies to check availability.
3. Clarify the specific message conveyed by the pharmacy regarding the medication.
4. If the member cannot find the medication, escalate the request by assigning it to the Prescribing Support Group( PSG Tier 1).
5. Add an internal note with the prescribing escalation template macro and the following information:
   • Original Pharmacy Name & Location
   • Details from the member (e.g., "Pharmacy is out of stock," "They don't carry this drug")
   • Member’s preferred alternative pharmacy

Medication Not Covered by Insurance

This is a common issue requiring coordination with the prescribing team.

1. Acknowledge the member's frustration: "I understand this can be frustrating. Let's see what we can do to resolve this."
2. Clarify the issue: Ask the member if the pharmacy is trying to fill a prescription from a Vida Medical Provider and if the issue is a prior authorization (PA) request. If not VMP, did non-Vida provider write the PA? Does the use-case allow non-Vida prescribers?
3. Gather key information from the member:
   • When was the last time you refilled this medication?
   • When was your last appointment with your Vida Medical Provider (VMP)?
   • Has the dosage of your medication changed recently?
4. Determine Escalation Path and Action:
   • If everything checks out (PA issue):
     • Add an internal note summarizing the issue and fill out the Prescribing Escalation Template macro including the following required fields for the Prior Auth or Pharmacy Related context:
       • Required Escalation Fields: Adv. Prescribing Team Code, Prescriber Name, Member's pay-org, Associated Program, and Member's state.
       • PA/Issue Details: Drug/dose, Insurance plan, Entity member spoke to (e.g., Pharmacy), and the Exact message member received (e.g., Prior Authorization required).
       • VMP Details: Last refill date, Last VMP appointment date, and Any recent dosage changes (Yes/No).
     • Assign the ticket to the Prescribing Support Group (PSG Tier 1).
   • If it is a general coverage issue (not PA-related):
     • The member may need to reach out directly to their insurance team to discuss coverage options.
     • Use the Prescription Cost macro to provide the member with resources.
5. Leave an internal note summarizing call.
6. Submit the ticket as Open. ⚠️