Agent Guide: Handling Calls for Medication & Coverage Interruptions

Comprehensive workflow for resolving medication interruptions, pharmacy rejections, and coverage gaps. Covers investigation steps (VP Card/Enrollment check), proper routing logic and required workflows.

1. The Agent Approach: Ownership & Direction

When a member calls regarding a medication gap or coverage denial, do not speculate on "system errors" or previous vendors. Instead, take immediate ownership of the investigation.

Your Goal: Determine the correct path based on the Organization's specific rules,  Use Case and the Member's current status.

Standard Script (The Opening):

"I can certainly assist you with this. I am opening your file and your organization's specific plan details right now to find out what is going on with the current prescription."

2. The Investigation Workflow

Before providing an answer, you must validate the facts using the following steps:

Step 1: Consult the Org-Specific Article  or VP Card

• Open the member's Organization (Pay Org) article in the knowledge base.

• Check the Use Case: Is this member in a program that covers GLP-1s? 

• Is the PayOrg's Use Case 1: Vida enrollment but non-Vida prescriber 

• Use Case 2: Vida or External,

• Use Case 3: Vida sole-prescriber

• Or a combination use case that requires a combination of engagement, enrollment, and possible Vida or non-Vida prescribing? 

• Check the Formulary Details: The Formulary is the "Covered Drug List" for a specific insurance plan. It acts as the rulebook that tells us if a drug is covered

• Ask the member if they have had a change in their prescription or dosage recently. If the med is prescribed outside of Vida, a new prescription will require their provider to submit a new PA.

Step 2: Check Enrollment & Program Status

• Look up the member in the the Health Guide Platform or in Admin under Users .

• Where are they in the process?

  • Pending: Have they completed their intake forms?

  • Incomplete: Are they missing labs or a provider visit?

  • Active: Are they fully enrolled and compliant with any engagement requirements?

• Note: If the member is not fully enrolled/compliant, this is often the cause of the coverage stop.

3. The Resolution Paths (Escalation Logic)

⚠️ CRITICAL AGENT NOTE:

The paths below outline the routing logic only. Before submitting any ticket, you must consult the specific KB article for that workflow to ensure you include all required fields and information. Incomplete tickets cause further delays.

Path A: The Script is from a Vida Medical Provider (VMP)

Scenario: The member is fully enrolled, and the prescription was written by a Vida Provider, but the pharmacy is blocking it.

Action: Escalate to the Prescribing Team.

Script:

"I have verified that your prescription was written by our clinical team. It appears the pharmacy needs a clarification or a renewed authorization from us directly.

Action: I am escalating this to our Prescribing Team immediately to provide the pharmacy with the necessary data. You will receive an update on this request within 48-72 hours."

Path B: Unresolved Eligibility or Claims Issues

Scenario: The member is eligible in our system, but the pharmacy sees them as "Inactive" or "Not Covered," indicating a file discrepancy between Vida and the PBM/Carrier.

Action: Escalate to  T2 to contact the Account Manager (AM) 

Script:

"I see that you are active and eligible in the Vida system, but there appears to be a discrepancy with how your eligibility is reflecting at the pharmacy.

Action: I am flagging this for our Account Management team to review the eligibility files with your employer's health plan. You will receive an update on this request within 48-72 hours."

Path C: Plan Design & PBM Issues

Scenario: The medication is excluded by the member's insurance, or they require a Prior Authorization that Vida cannot manage (e.g., they are not in a Prescribing Use Case).

Action: Direct the member to their Insurance Carrier or PBM.

Script:

"Based on your organization's plan design, this specific request requires approval directly from your insurance carrier's Pharmacy Benefit Manager (PBM). Vida does not have the authority to override this specific plan exclusion.

Action: Please call the Member Services number on the back of your insurance card. You will need to ask them for the specific 'Coverage Criteria' for this medication. Once you have that, let us know if we can assist with documentation."

Path D: Missing Engagement Credit or VBID Status (Use Case 1  or Dell)

Scenario: The member is in Use Case 1 (Engagement-Based) or part of Dell’s Preferred Pricing Program. They claim to have met all engagement requirements (e.g., webinar attendance, logging), but the app shows them as "Non-Compliant" or the pharmacy price has not updated. 

Action: Escalate via Jira Ticket.

Script:

"Thank you for confirming those activities. It appears there may be a delay in your engagement data syncing to your coverage status in our system.

Action: I am filing a technical support ticket right now to have our engineering team verify your activity logs and manually push your 'Compliant' status to the pharmacy benefit system. This typically takes 48 hours to reflect at the pharmacy."

Summary Checklist for Agents