Podcast
Questions and Answers
Match the terms
Match the terms
co-insurance = an agreement for cost-sharing between the insurer and the insured co-pay = the portion of the medication's price that the patient is required to pay dual co-pay = co-pays that have two prices: one for generic and one for brand medications maximum allowable cost (MAC) = the maximum price per tablet (or other dispensing unit) an insurer or PBM will pay for a given product
Match the terms
Match the terms
online adjudication = the resolution of prescription coverage through the communication of the pharmacy computer with the third-party computer pharmacy benefit managers = companies that administer drug benefit programs (PBM) UCR = the maximum amount of payment for a given prescription, determined by the insurer to be a usual and customary (and reasonable) price deductible = a set amount that must be paid by the patient for each benefit period before the insurer will cover additional expenses
Match the terms
Match the terms
formulary = a list of medications covered by third-party plans prescription drug benefit card = cards that contain third-party billing information for prescription drug purchases tier = categories of medications that are covered by third-party plans HMOs = cost are covered only for services from in-network providers
Match the terms
Match the terms
Match the terms
Match the terms
Match the terms
Match the terms
Match the terms
Match the terms
Companies that administer drug benefit programs are called
Companies that administer drug benefit programs are called
Another party, besides the patient or the pharmacy, that pays some or all of the cost of the medication is a (an)
Another party, besides the patient or the pharmacy, that pays some or all of the cost of the medication is a (an)
The prescription drug co-pay is paid by
The prescription drug co-pay is paid by
Plans in which the patient pays a different amount depending on whether a generic or brand name medication is dispensed have
Plans in which the patient pays a different amount depending on whether a generic or brand name medication is dispensed have
Generic drugs are usually in tier
Generic drugs are usually in tier
A (an) ____________ is a network of providers for which costs are covered inside, but not outside of the network
A (an) ____________ is a network of providers for which costs are covered inside, but not outside of the network
A (an) ____________ is a network of providers where costs outside the network may be partially reimbursed and the patient's primary care physician need not be a member
A (an) ____________ is a network of providers where costs outside the network may be partially reimbursed and the patient's primary care physician need not be a member
Which type of managed care program is least likely to require generic substitution
Which type of managed care program is least likely to require generic substitution
Medicare Part D covers
Medicare Part D covers
Closed formulary programs, such as Medicaid, may cover drugs not on the formulary through a process called
Closed formulary programs, such as Medicaid, may cover drugs not on the formulary through a process called
The rules for coordination of benefits ensure that the benefit coverage for a claim does not exceed ____ of the total cost
The rules for coordination of benefits ensure that the benefit coverage for a claim does not exceed ____ of the total cost
When there is a question on insurance coverage for an online claim, the pharmacy technician can
When there is a question on insurance coverage for an online claim, the pharmacy technician can
When a technician receives a rejected claim "Invalid Person Code", this probably means
When a technician receives a rejected claim "Invalid Person Code", this probably means
A standard form used by health-care providers to bill for services is
A standard form used by health-care providers to bill for services is
The CPT codes for billing Medication Therapy Management services provided by pharmacists are
The CPT codes for billing Medication Therapy Management services provided by pharmacists are
Calculate the days supply for the following prescription:
Amoxicillin 500 mg #45 Sig: i cap t.i.d
Calculate the days supply for the following prescription:
Amoxicillin 500 mg #45 Sig: i cap t.i.d
Calculate the days supply for the following prescription:
Ampicillin 250 mg/5mL Dispense 200 mL Sig: 5 mL q.i.d
Calculate the days supply for the following prescription:
Ampicillin 250 mg/5mL Dispense 200 mL Sig: 5 mL q.i.d
Medicare is administered by the
Medicare is administered by the
Which type of managed care program usually has the most restrictions
Which type of managed care program usually has the most restrictions
One way to obtain coverage of non-formulary medication is
One way to obtain coverage of non-formulary medication is
What is the most likely reason for a rejected claim with the message "refills not covered"?
What is the most likely reason for a rejected claim with the message "refills not covered"?
What can a technician do if a prescription claim is rejected for invalid day supply?
What can a technician do if a prescription claim is rejected for invalid day supply?
Patient assistance programs are offered by
Patient assistance programs are offered by
A company that administers a drug benefit program is
A company that administers a drug benefit program is
Coordination of benefits occurs when there is/are
Coordination of benefits occurs when there is/are
You're filling a prescription for enalapril 10 mg #30, i tab every day. What is the days supply?
You're filling a prescription for enalapril 10 mg #30, i tab every day. What is the days supply?
The prescription is written for Augmentin 500 mg #45, with directions to take 1 tablet 3 times a day. What is the days supply?
The prescription is written for Augmentin 500 mg #45, with directions to take 1 tablet 3 times a day. What is the days supply?
The amount paid by a co-insurer to the pharmacy is equal to the wholesale price of a drug
The amount paid by a co-insurer to the pharmacy is equal to the wholesale price of a drug
Medicare and Medicaid are examples of public health insurance programs
Medicare and Medicaid are examples of public health insurance programs
A pharmacy benefits manager is a company that administers drug benefits programs
A pharmacy benefits manager is a company that administers drug benefits programs
Tier one drugs are usually generics
Tier one drugs are usually generics
Many third-party programs have drug formularies
Many third-party programs have drug formularies
Prior authorization is a procedure to gain third-party coverage for a drug that is not automatically covered by a third-party plan
Prior authorization is a procedure to gain third-party coverage for a drug that is not automatically covered by a third-party plan
The CMS-1500 form is used to apply for a NPI
The CMS-1500 form is used to apply for a NPI
An NPI number identifies the pharmacy
An NPI number identifies the pharmacy
The resolution of prescription coverage for a prescription through the communication of the pharmacy computer with the third-party computer is called
The resolution of prescription coverage for a prescription through the communication of the pharmacy computer with the third-party computer is called
The maximum allowable cost (MAC) is usually _____ the usual and customary (U&C) price
The maximum allowable cost (MAC) is usually _____ the usual and customary (U&C) price
The ___________ is the maximum price per unit an insurer will pay for a product
The ___________ is the maximum price per unit an insurer will pay for a product
_________ is a program for people over age 65 or with certain disabilities
_________ is a program for people over age 65 or with certain disabilities
The medicare program that covers inpatient hospital expenses is
The medicare program that covers inpatient hospital expenses is
Procedures for billing compounded prescriptions
Procedures for billing compounded prescriptions
When a technician receives a rejected claim, "invalid birth date," this probably means
When a technician receives a rejected claim, "invalid birth date," this probably means
The form used by health-care providers to apply for a national provider identifier (NPI) is
The form used by health-care providers to apply for a national provider identifier (NPI) is
An online platform for MTM
An online platform for MTM
