Community Pharamcy Theory cirrus test 1

A case worker or adjuster will need to be contacted for drug claims for

workers compensation

An employer offers a high-deductible insurance plan. What else can be offered by the employer to help pay medical expenses and serve as a tax-deferred benefit?

both HSA and FSA

A patient has a new prescription for a heart medication and provides the technician with two prescription insurance cards. Which should be processed first?

Primary Insurance

A patient of limited means who is without healthcare insurance should be referred to the___________to select and purchase a low-cost plan.

the state's on-line Affordable Care healthcare exchange

At your pharmacy, you need to process a claim for blood-glucose monitoring strips for a patient on Medicare A and B. The Centers for Medicare and Medicaid have a Level II Healthcare Common Procedure Coding System (HCPCS) that addresses that particular item. But you will need a supportive diagnosis code. What kind of code will you need?

ICD-10

During which step in processing a claim does the technician or pharmacist learn if a drug is on the formulary for a specific insurance plan?

on-line adjunction

Express Scripts International (ESI) and CVS Caremark are examples of

pharmacy benefit managers

If your insurance is a Preferred Provider Organization (PPO) and you go to a provider out-of-network, you will

pay higher copays and fees

In the tiered copayment system, the patient pays

**a different fee up front depending on the expense level of the service.**

Medicare Part B covers some durable medical supplies and the medications that go with them. Which drug used to treat chronic obstructive pulmonary disease (COPD) is covered by Medicare Part B?

albuterol nebulizing solution

Mr. and Mrs. White are long-term patients at your pharmacy. When their insurance annual re-enrollment occurred, they found a less expensive plan and your pharmacy is not enrolled with this company. What should you do?

**Prior to filling tell them what pharmacies do take their plan.**

Mr. Chamberlin is a 54-year-old retired military veteran. What type of insurance coverage is available for him?

Tricare

Mr. Jones has a prescription for Protonix. You submit a claim to his insurance for the generic equivalent, pantoprazole, but get a rejection code that this drug is not covered, and omeprazole is the plan preferred drug. What should you do?

**have the pharmacist call the prescriber for a therapeutic substitution**

Technicians should remind patients it is time to renew their healthcare exchange insurance during what months?

November to January

The amount of money the patient pays in regular (monthly, quarterly, or annual) increments for health insurance coverage is called the

premium

The pharmacy is notified of a charge-back due to an incorrect coordination of benefits. Who loses the money for the claim?

the pharmacy

Under the Affordable Care Act, a business with more than ______full-time employees must offer healthcare insurance.

50

What federal act established drug benefits for senior citizens on Medicare?

**Medicare Modernization Act of 2003**

What information on a patient's prescription card tells the technician which PBM is administering the drug plan?

**bank identification number**

What is/are the reason(s) the cost of prescription drugs is outpacing the rate of inflation?

**manufacturers increase AWP for both brand and generic drugs, fewer drug patent expirations, increase in expensive innovative drugs**

What is the low-cost-to-free healthcare insurance program available for children 0 to 19 years old whose parents earn over the poverty level but not enough to purchase healthcare insurance?

CHIP

What term refers to the amount wholesalers charge the pharmacy for a drug, which serves as a benchmark price for pharmacy benefit managers to estimate reimbursement rates?

average wholesale price

When an employee is injured on the job, the pharmacy technician will generally bill the prescription services related to the injury to

workers compensation Insurance

When employees leave a job, the employer must give the employees the option to pay full premiums to continue with their present insurance plan. This is called

COBRA Insurance

Which federal program provides healthcare to United States citizens over 64 years of age and those who are disabled?

Medicare

Which of the following is considered preventive care and covered by most insurance plans?

immunizations

Who is considered the third party in terms of payment of prescriptions?

insurance company

A preferred drug list established by the insurer and administered by a Pharmacy Benefits Manager is called a(n)

formulary

The information from a drug insurance card required to process a prescription claim for insurance includes the

patient ID number, BIN, and effective date

What is the term for the amount of annual medical costs that must be paid by the insured before the insurance company will consider paying its portion?

deductible

In the tiered copay prescription system,

**there are escalating costs for generic drugs, preferred brands, and nonpreferred brands**

What is the advantage of supplemental health insurance?

**pays for some services not covered by primary insurance**

Workers' compensation

**covers illness or injuries caused by or related to one's job.**

A patient hands you two insurance cards to use to pay for her prescriptions. The insurance plan that you must bill for any amount not covered by the other insurance company is called the

secondary plan

What is one reason that healthcare costs are rising?

**increase in innovative high cost drugs**

An incorrect birthdate is in the pharmacy database and the PBM database of the insurance company. What step would NOT be appropriate?

**The patient asks the pharmacy to correct the date and send a change notification to the insurance company.**

What is the usual rationale for a pharmacy benefit manager to conduct an audit of a pharmacy's claims?

catch fraud and deduce waste

Medication Therapy Management (MTM) can only be billed to Medicare by the pharmacist if the pharmacist is contracted by

**a Medicare-approved health center or clinic.**

A pharmacy technician can help Mrs. Lang, an elderly patient with diabetes on Medicare Part B, by

\n **explaining the insurance Part B coverage for diabetes supplies**

What is online adjudication?

\n **real-time insurance claims processing via telecommunications**

A 67-year-old patient wishes to purchase a wheelchair from your pharmacy. She has Medicare A and B, and her physician says it is medically necessary. What form must be completed to get her insurance to cover the cost?

**Certificate of Medical Necessity**

Mrs. McGillicutty works for a large company and knows she is going to have $675 in health care costs this year over what her insurance will pay. There is an employer-based option to put aside pretax dollars from her paychecks for these costs over the year, but she must plan carefully and use the funds up within the year or they will be lost. What is this program?

flexible Spending Account

In which type of healthcare insurance is the patient assigned a primary care physician within its system who must provide a referral for specialized services?

The HMO assigns (or the patient chooses) a primary provider within the HMO system to act as a gatekeeper for the rest of the services provided to the patient.

What may be required if a physician prescribes a medication that is NOT on the insurance company's formulary?

**prior authorization**

The Affordable Care Act requires employers with more than 50 full-time employees to

**offer a health insurance option.**

Your pharmacy has a list of 25 drugs that they offer for $4 for a month supply. These are known as

loss leaders

What is NOT a reason for a drug utilization alert DUR?

**The drug is prescribed by a provider not on the preferred prescriber list**

Which group(s) of patients is (are) eligible for Medicare

Age, chronic kidney disease, ALS, or receiving Social Security disability insurance (SSDI) payments for over 24 months makes you eligible for Medicare benefits.

When sending a claim to the insurance company, you incorrectly calculate the days' supply. It was supposed to be 30 days, but you submitted 90 days. The patient is back for a refill, and the insurance will not pay. What do you tell the patient?

**You need to call the insurance and correct your mistake before you can refill the prescription.**

When a patient has more than one insurance covering prescriptions, filing the prescription claim in the correct order with the different PBMs of the insurance companies is called

\n **coordination of benefits**

You have an insurance that requires you to pay up front 20% of all costs. This is an example of

\n **a coinsurance payment**