Financial Issues

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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

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

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

POS = the patient's primary care physician must be a member; an costs outside the network may be partially reimbursed PPO = cost outside the network may be partially reimbursed and the patient's primary care physician need not be a member Medicaid = a federal-state program, administered by the states, providing health care for the needy Medicare = a federal program providing health care to people with certain disabilities or who are over age 65 Signup and view all the answers

Match the terms

patient assistance programs = manufacturer sponsored prescription drug programs for the needy worker's compensation = an employer compensation program for employees accidentally injured on the job prior authorization = a procedure to gain third-party coverage for a drug that is not automatically covered by a third party plan CMS-1500 form = the standard form used by health-care providers to bill for services, including disease state management services Signup and view all the answers

Match the terms

universal claim form (UCF) = a standard claim form accepted by many insurers CMS-10114 form = the standard six-page form used by health-care providers to apply for a national provider identifier (NPI) Current Procedural Terminology codes (CPT codes) = identifiers used for billing pharmacist-provided MTM services Medication Therapy Management (MTM) services = services provided to some Medicare beneficiaries who are enrolled in Medicare Part D and who are taking multiple medications or have certain diseases Signup and view all the answers

Match the terms

National Provider Identifier (NPI) = the code assigned to recognized health-care providers; needed to bill MTM services Prescription Drug Plans (PDPs) = third-party programs for Medicare Part D a = b c = d Signup and view all the answers

Companies that administer drug benefit programs are called

pharmacy benefit managers Signup and view all the answers

Another party, besides the patient or the pharmacy, that pays some or all of the cost of the medication is a (an)

third-party Signup and view all the answers

The prescription drug co-pay is paid by

the patient Signup and view all the answers

Plans in which the patient pays a different amount depending on whether a generic or brand name medication is dispensed have

dual co-pays Signup and view all the answers

Generic drugs are usually in tier

one Signup and view all the answers

A (an) ____________ is a network of providers for which costs are covered inside, but not outside of the network

HMO Signup and view all the answers

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

PPO Signup and view all the answers

Which type of managed care program is least likely to require generic substitution

PPO Signup and view all the answers

Medicare Part D covers

prescription drugs Signup and view all the answers

Closed formulary programs, such as Medicaid, may cover drugs not on the formulary through a process called

prior authorization Signup and view all the answers

The rules for coordination of benefits ensure that the benefit coverage for a claim does not exceed ____ of the total cost

100% Signup and view all the answers

When there is a question on insurance coverage for an online claim, the pharmacy technician can

telephone the insurance plan's pharmacy help desk Signup and view all the answers

When a technician receives a rejected claim "Invalid Person Code", this probably means

the person code entered does not match the birth date and/or sex in the insurer's computer Signup and view all the answers

A standard form used by health-care providers to bill for services is

CMS-1500 Signup and view all the answers

The CPT codes for billing Medication Therapy Management services provided by pharmacists are

99605, 99606, 99607 Signup and view all the answers

Calculate the days supply for the following prescription:

Amoxicillin 500 mg #45 Sig: i cap t.i.d

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Calculate the days supply for the following prescription:

Ampicillin 250 mg/5mL Dispense 200 mL Sig: 5 mL q.i.d

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Medicare is administered by the

CMS Signup and view all the answers

Which type of managed care program usually has the most restrictions

HMO Signup and view all the answers

One way to obtain coverage of non-formulary medication is

prior authorization Signup and view all the answers

What is the most likely reason for a rejected claim with the message "refills not covered"?

the insurance plan has mail-order requirements Signup and view all the answers

What can a technician do if a prescription claim is rejected for invalid day supply?

dispense a lesser amount and adjust refills Signup and view all the answers

Patient assistance programs are offered by

pharmaceutical manufacturers Signup and view all the answers

A company that administers a drug benefit program is

a pharmacy benefit manager Signup and view all the answers

Coordination of benefits occurs when there is/are

two different health insurance plans that provide coverage for the same prescription Signup and view all the answers

You're filling a prescription for enalapril 10 mg #30, i tab every day. What is the days supply?

30 Signup and view all the answers

The prescription is written for Augmentin 500 mg #45, with directions to take 1 tablet 3 times a day. What is the days supply?

15 Signup and view all the answers