Cognitive Services Intervention Form
All Fields Required:
Member Last Name
*
Member First Name
*
Phone Number
(
)
-
*
Member Client Index Number (CIN)
*
Date of Service
Jan
Feb
Mar
Apr
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Nov
Dec
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2024
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2012
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Prescription Number(s)
*
Pharmacy NCPDP #
*
Pharmacy Name
*
Pharmacy Phone Number
(
)
-
*
Pharmacist Name
*
Pharmacist NPI#
*
Please check the box to the intervention performed:
HIV/AIDS ($20 per calendar quarter per member)
Contacted the prescribing physician regarding a dosage adjustment or potentially serious drug interaction.
Provided counseling on a complicated medication regimen (which may include the use of a compliance device).
Asthma ($10 per calendar quarter per member)
Gave individualized instruction on proper use of metered dose inhalers or dry powder inhalers, spacers and/or peak flow meters.
Educated an asthmatic member of the benefit of complying with inhaled steroids (or other long term controllers) and the need for regular, scheduled use for chronic management of asthma.
Intervened with the prescriber when excessive use of a beta-agonist inhaler is identified and an inhaled steroid (or other long-term controller) has not been prescribed.
Recommended the use of a spacer for a member receiving an inhaled steroid via pressurized metered-dose inhaler.
Diabetic Retinal Eye Exam ($10 per member per year)
Asked diabetic members if they have had a dilated retinal eye exam within the past year.
Documented eye exam information or educated members regarding the importance of an annual eye exam.
Emergency Contraception ($20; limited to 2 interventions per member per year)
Furnished emergency contraception medications based on the statewide protocol adopted by the California State Board Pharmacy and the Medical Board of California
(www.pharmacy.ca.gov/licensing/ec_protocol.pdf)
.
Educated the member regarding the proper dosing instructions.
If you have any questions feel free to call CalOptima Pharmacy Management at:
714-246-8471. Thank you.
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