Chapter 8 EOC

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

average wholesale price

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

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

Which federal program provides healthcare to U.S.citizens over 65 years of age and those who are disabled?

Medicare

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

Tricare

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

premium

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

the insurance company

Miss Chips has a deductible of $1000. She has seen her doctor 3 times at $150/visit, gone to the ER once at $800, and has had lab work done totaling $750. How much will be paid by her insurance if it covers 100% after she has reached her deductible?

$1,000

In the tiered copayment system, the patient pays

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

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 the particular supply. But you will need a supportive diagnosis code. What kind of code will you need?

ICD-10

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?

health savings account (HSA) and flexible spending account (FSA)

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

COBRA insurance

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

pay more for the copayments and/or other fees.

Which of the following is considered preventable care and covered by most insurances?

immunizations

When an employee is hurt on the job, the pharmacy technician will generally be billing the prescription services related to the injury to __________________.

workers’ compensation insurance

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

Medicare Modernization Act of 2006

Pharmacies do NOT bill any prescription drugs or services to this Medicare program:

Part A

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. Murphy has a Medicare Part D plan that does not have a deductible but requires him to pay 25% of his prescription costs until he is in the donut hole (after $2960 in expenses but before catastrophic insurance kicks in). His prescriptions cost a total of $425/month. In what month will he start paying 100% of the drug costs?

July

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

CHIP

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

50

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

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

November to January

Mr. and Mrs. White are long-term patients at your pharmacy. When the 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.

Merck, Express Scripts International (ESI), CVS Caremark, and MEDCO are all examples of

pharmacy benefits managers (PBMs).

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

band identification number

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

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 adjudication

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

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

workers’ compensation

Timolol ophthalmic solution is available in 5 mL, 10 mL and 15 mL bottles. Mr. Schmidt is supposed to place 1 drop OS every night at bedtime. His insurance will only pay for a month supply at a time. Which size bottle should be dispensed? (16 drops = 1 mL is the standard conversion used by this insurance company.)

5 mL

Mrs. Solanus uses Lantus Solostar Pens that are supplied in boxes of 5 pens. Each pen has 3mL of 100 unit/mL insulin glargine. If her prescription directions are “Inject 45 units subcut at bedtime,” how many boxes will she need for a 90-day supply?

3

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

the pharmacy

Due to federal kickback laws, which insurance type (s) do NOT allow the use of coupons or drug discount cards?

Medicare Part D, Tricare, Medicaid

A patient has two prescriptions and no insurance coverage. One is for lisinopril 20 mg, and the other is for hydrochlorothiazide 12.5 mg. How might the technician recommend saving the patient money on the prescriptions?

Get the prescription changed to a combination drug and have the pharmacist check for a discount.

A common message that comes through online adjudication for high-cost medications is

NDC Not Covered

What is the benefit of catastrophic insurance to young, healthy people?

low premium

Patients can use their health savings account debit card to pay for

copays

Who needs to apply for prior approval of a drug not on formulary of an insurance plan?

prescriber

A patient has a prescription for diazepam 5mg #30, Take 1 tablet up to BID prn anxiety. The patient had it filled 5 days ago and wants a refill. What type of rejection will occur during processing?

Refill too soon

Your pharmacy is being audited by the PBM and is asked to prove Mr. Wilson received a specific medication that has been claimed. What should you do?

Give the auditor copies of the signature log.