SWARM CCR Checklist


  1. CCR First Name


  1. CCR Last Name


  1. CCR UID/ZID


  1. Location
    Fort Pierce
    Yuma


  1. Date/Time of Call (MM/DD, HH;MMxm)


  1. Client Code


  1. Drug Name


  1. Drug Strength


  1. Drug Dosage


  1. Call type
    Tiering
    Non-Formulary
    PA Request
    Other


  1. Validate medication requires a PA, is a Formulary drug, or a Non-Formulary drug via claim or test claim?
    Yes
    No
    N/A


  1. PA, QL or Step Therapy Request
    Did the CCR educate member about the drug coverage of PA required?
    Yes
    No


  1. PA, QL or Step Therapy Request
    Did the CCR correctly transfer to the CDA team to initiate the PA (not the CD Specialized Team)?

    Yes
    No


  1. PA, QL or Step Therapy Request
    Did the CCR offer any alternatives for the PA required medication?
    Yes
    No


  1. PA Status
    Did the CCR check the PA history screen for the PA status?
    Yes
    No


  1. PA Status
    Did the CCR educate the member about the status of the PA request?
    Yes
    No


  1. PA Status
    Did the member accept the PA status information provided by the CCR?
    Yes
    No


  1. PA Status
    Did the CCR transfer the call to the CD Specialized team for additional assistance?
    Yes
    No


  1. PA Status
    Did the CCR transfer the call to the CD&A team for additional assistance?
    Yes
    No


  1. Non-Formulary Request
    Did hte CCR educate the member about the drug coverage of non-formulary?
    Yes
    No


  1. Non-Formulary Request
    Did the CCR transfer to the Specialized team for alternatives?
    Yes
    No


  1. Non-Formulary Request
    Did the member specifically request an Exception or did not want to be transferred for alternatives?
    Yes
    No


  1. Formulary/Tier Request
    Did the CCR validate what tier the medication falls in?
    Tier 1
    Specialty
    Tiers 2-4


  1. Fomulary/Tier Request
    Tier 1
    Was the member satisfied with the Tier 1 response?
    Yes
    No


  1. Formulary/Tier Request
    Tier 1
    Did the CCR offer the member lower cost alternatives via the CD Specialized Team?
    Yes
    No


  1. Formulary/Tier Request
    Tier 1 - lower cost alternatives
    If the member accepted, did CCR correctly warm transfer to the CD Specialized Team?
    Yes
    No


  1. Formulary/Tier Request
    Tier 1 - lower cost alternatives
    Did hte member specifically request an Exception or did not want to be transferred for alternatives?
    Yes
    No


  1. Formulary/Tier Request
    Tiers 2-4
    Did the CCR educate the member about drug coverage?
    Yes
    No


  1. Fomulary/Tier Request
    Tiers 2-4
    Was the member satisfied with the response?
    Yes
    No


  1. Formulary/Tier Request
    Tiers 2-4
    Did the CCR offer the member lower cost alternatives via the the Care CD Specialized Team?
    Yes
    No


  1. Formulary/Tier Request
    Tiers 2-4
    If the member accepted, did the CCR correctly warm transfer to the Care CD Specialized Team?
    Yes
    No


  1. Formulary/Tier Request
    Tiers 2-4
    Did the member specifically request an Exception or did not want to be transferred for alternatives?
    Yes
    No


  1. Formulary/Tier Request
    Tier 5
    Did the CCR transfer to the Specialty Team?
    Yes
    No


  1. Documentation
    Did the CCR completely document the caller's request and outcome in their View Activity Comments for audit purposes?
    (include supporting details, capturing the 5 W's - Who, What, When, Why and Where)
    Yes
    No


  1. Provide additional comments or coaching





Guy Macdonald