Learning Objectives
In this module, you will learn how to identify and resolve:
- Pharmacy Not Contracted rejections with StoreNet procedures
- Drug Not Formulary rejections and CMS appeal rights
- Prior Authorization requirements and documentation
Rejection Type 7: Pharmacy Not Contracted
Pharmacy Not Contracted with Plan - Use StoreNet Form
What it means: The pharmacy is not enrolled or contracted with the patient's insurance plan. The plan does not recognize the pharmacy as an authorized network provider.
Processor message: "*WAG*Walgreens store not enrolled, scan ID card. Fill out Form on StoreNet>Patient Care>Pharma Partner/Consignment). Access Changes"
Additional message: "CON CLAIMS NOT ALLOWED PHARMACY NOT CONTRACTED"
Resolution Steps:
- Recognize the rejection type:
- Message indicates "CON claims not allowed"
- Pharmacy not contracted with this specific plan
- This is a store-level enrollment issue
- Access StoreNet to complete enrollment:
- Log into StoreNet on the pharmacy computer
- Navigate to: StoreNet > Patient Care
- Select: Pharma Partner/Consignment section
- Locate the enrollment form for this insurance plan
- Complete the enrollment form:
- Fill out all required store information
- Scan patient's insurance ID card as instructed
- Upload scanned card image to the form
- Verify all information is accurate
- Submit enrollment form:
- Review completed form for errors
- Submit for processing
- Note confirmation number if provided
- Document submission date and time
- Wait for processing:
- Enrollment typically takes 24-48 hours
- Some plans process faster (same day)
- Store will receive confirmation when enrollment is complete
- For immediate patient needs:
- Transfer to contracted pharmacy:
- If patient needs medication urgently
- Find nearest contracted location
- Transfer prescription electronically
- Process as cash with reimbursement promise:
- Patient pays cash now
- Resubmit to insurance once enrolled
- Patient submits receipt for reimbursement
- Check for alternative insurance:
- Does patient have secondary insurance?
- Different plan may be accepted
- Transfer to contracted pharmacy:
- Follow up on enrollment status:
- Check StoreNet for confirmation
- Verify enrollment was approved
- Test by submitting a claim
- Once enrolled, resubmit claim:
- Process prescription through newly activated plan
- Claim should now be accepted
- Contact patient if they're waiting for enrollment
Rejection Type 8: Drug Not Formulary
Drug Not Formulary - Provide Patient with CMS Notice of Appeal Rights
CRITICAL REQUIREMENT:
You MUST provide the patient with a CMS Notice of Appeal Rights form for all non-formulary rejections. This is a legal requirement for Medicare and many other plans.
What it means: The prescribed medication is not covered under the patient's insurance plan formulary. The plan either doesn't cover this drug or requires alternatives to be tried first.
Additional message: "IF LEVEL OF CARE CHANGE CALL HELP DESK. CLOSED FORM *WAG*Non-Form Product- Potential Alternatives are: [alternative medications listed]"
Example alternatives: "52937000120 - VASCEPA Plan Helpdesk Number: 8778135595"
Resolution Steps:
- REQUIRED: Provide CMS Notice of Appeal Rights
- Locate the CMS Notice of Appeal Rights form
- Give copy to patient or mail if not present
- This is MANDATORY for non-formulary rejections
- Explain patient's right to appeal the decision
- Review list of covered alternatives:
- Additional messages provide alternative medications
- Note NDC numbers and medication names
- These are medications the plan WILL cover
- Contact prescriber to discuss formulary alternatives:
- Call or fax prescriber's office
- Inform them of non-formulary rejection
- Share the list of covered alternatives from rejection message
- Ask: "Would you like to prescribe [alternative medication] instead?"
- If prescriber wants to continue with non-formulary drug:
- Request prior authorization from prescriber
- Provide PA helpdesk number from rejection (e.g., 8778135595)
- Prescriber must submit:
- Medical necessity documentation
- Clinical justification
- Why alternatives are not appropriate
- If "level of care change" applies:
- Call the help desk as instructed
- Provide claim details and situation
- Follow help desk guidance
- Explain situation to patient:
- "Your insurance doesn't cover [medication]. They prefer [alternatives]."
- "Your doctor can prescribe the alternative or request approval for the original."
- "Here's your Notice of Appeal Rights - you can appeal this decision."
- Options while waiting for PA or appeal:
- Process as cash: Quote cash price if patient can afford
- Check manufacturer discount programs: Savings cards may reduce cost
- Fill smaller quantity as bridge: Smaller supply until PA approved
- Use alternative: If prescriber writes for formulary option
- If PA is approved:
- Obtain PA reference number
- Enter PA number into system
- Resubmit claim
Rejection Type 9: Prior Authorization Required
M/I Prior Authorization Support Documentation
What it means: The insurance requires prior authorization (PA) before they will cover this medication. The prescriber must submit clinical documentation proving medical necessity.
Common scenario: High-cost medications, specialty drugs, or medications with specific coverage criteria require PA approval before dispensing.
Example message: "Supporting CMN Documentation Required"
Resolution Steps:
- Review processor message for PA requirements:
- Note PA contact phone/fax numbers
- Check for CMN (Certificate of Medical Necessity) requirements
- Look for any specific documentation needed
- Note any supporting documentation required:
- CMN (Certificate of Medical Necessity)
- Lab results or test values
- Previous medication trial documentation
- Diagnosis codes (ICD-10)
- Medical chart notes
- Contact prescriber's office:
- Call or fax the prescriber
- Inform them PA is required for this medication
- Provide insurance PA phone/fax numbers
- Share specific documentation requirements
- Request they submit PA with clinical justification
- Information to provide prescriber:
- Patient name and date of birth
- Insurance plan name and ID number
- Medication name, strength, quantity, and sig
- PA phone number from rejection message
- List of required documentation
- Explain to patient:
- "Your insurance requires prior approval for this medication."
- "Your doctor needs to submit paperwork showing why you need this specific drug."
- "The PA process typically takes 24-72 hours."
- "The pharmacy will process your prescription once it's approved."
- Check if urgent/emergency supply available:
- Some plans allow emergency fill pending PA
- Usually 3-7 day supply while PA is processed
- May process smaller quantity as cash bridge
- Check additional messages for emergency fill options
- Document all communications:
- Note date/time of prescriber contact
- Record who you spoke with at prescriber's office
- Document PA request details
- Note patient notification
- Once PA is approved:
- Obtain PA reference number from prescriber or insurance
- Enter PA number in appropriate field in system
- Resubmit claim
- Verify claim processes successfully
- Contact patient that prescription is ready
- Follow up if PA is taking too long:
- Call prescriber after 2-3 days if no response
- Check PA status with insurance
- Update patient on timeline
- Offer bridge supply if patient needs medication
Key Takeaways
- Pharmacy not contracted requires StoreNet enrollment (24-48 hour process)
- Drug not formulary REQUIRES providing CMS Notice of Appeal Rights to patient
- Prior authorization must be initiated by prescriber, not pharmacy
- Always provide patients with realistic timelines and alternative options
- Document all prescriber contacts, PA numbers, and patient communications