Reimbursement

Front 1

___________ fee compensates a pharmacy for transferring a drug to the patient, overhead costs, and patient counseling.

Back 1

Dispensing fee

Front 2

a patient can visit any doctor without choosing a primary care physician, and pay smaller co-pays for in-network providers but have larger out-of-pocket costs for providers outside of the network.

Back 2

PPO preferred provider organization

Front 3

examples of government sponsored health insurance programs.

Back 3

Medicare

Medicaid

Tricare

Front 4

insurance program that provides benefits for employees who become injured or ill as a direct result of their job.

Back 4

Worker's compensation

Front 5

Medicare covers:

Back 5

senior citizens, individuals with disabilities, and those receiving dialysis

Front 6

refers to the maximum amount that a plan will pay for generic drugs and brand name drugs that have a generic available.

Back 6

MAC max allowable cost

Front 7

parts of Medicare covers certain vaccines that are administered to a patient at a pharmacy?

Back 7

Part D

Front 8

refers to the amount of money that must be paid on an annual basis before a co-pay applies.

Back 8

Deductible

Front 9

Deductibles for a prescription insurance plan are reset every

Back 9

Calendar year

Front 10

amount the patient must spend each year on prescription drugs before the insurance plan will start to make payments for covered prescriptions.

Back 10

Deductible

Front 11

preset annual cost that must be paid by a patient before an insurance company will begin paying towards the cost of a prescription?

Back 11

Deductible

Front 12

refers to the percentage cost that a patient pays for a medication?

Back 12

Co Insurance

Front 13

parts of Medicare offers prescription drug plans?

Back 13

Part D

Front 14

four parts to Medicare benefits.

Back 14

Part A is the hospital insurance plan

Part B is the medical coverage plan that covers doctor's visits, outpatient procedures, and laboratory tests, among other things.

Part C is the private insurance option known as Medicare Advantage.

The newest addition to Medicare is Part D, which helps pay for prescription drugs. It is optional and available to people who are enrolled in "Original Medicare" (Parts A and B) and most Medicare Advantage plans.

Front 15

Medicaid covers which of the following groups?

Back 15

covers pregnant women, individuals with disabilities, and those below a certain income level.

Front 16

parts of Medicare covers durable medical equipment (DME)?

Back 16

Part B

Front 17

any equipment that provides therapeutic benefits to a patient in need because of a medical condition or illness. These are things such as wheelchairs, hospital beds, traction equipment, canes, crutches, walkers, kidney machines, ventilators, oxygen, monitors, pressure mattresses, lifts, nebulizers, bili blankets, and bili lights.

Back 17

durable medical equipment (DME).

Front 18

refers to the coverage gap in Medicare Part D that occurs when the cost of a patient’s prescriptions in a given year exceeds a certain amount?

Back 18

Donut hole

Front 19

parts of Medicare covers nursing care and hospital stays?+

Back 19

Part A

Front 20

strategies used by pharmacy benefit managers to contain drug costs.

Back 20

tiered co-pay structure,

prior authorizations, and

formulary management

Front 21

contains drug pricing information such as the average wholesale price (AWP) and suggested retail price.

Back 21

Red book

Front 22

parts of Medicare is a private insurance option that is also known as Medicare Advantage?

Back 22

Part C

Front 23

type of insurance that a consumer receives through his/her employer (or a family member’s employer) or through individual purchase.

Back 23

Private insurance

Front 24

With a ______________ co-payment arrangement, co-pays can change depending on the medication being dispensed.

Back 24

Variable

Front 25

insurance plans that are federal programs for patients who are elderly, disabled, receiving dialysis, or low-income.

Back 25

Medicare & Medicaid

Front 26

Diff between Medicare and Medicaid

Back 26

Medicaid provides health coverage for some low-income people, families and children, pregnant women, the elderly, and people with disabilities. Medicaid coverage is based on income and family size.

Medicare is health coverage available to any person over the age of 65 years old, or those under the age of 65 that are receiving Social Security Disability Insurance (SSDI). Additionally, those under the age of 65 with End-Stage Renal Disease (ESRD) qualify for Medicare.

Front 27

insurance plans can a patient choose a primary care physician from a network of providers, and that physician coordinates his/her care?

Back 27

health maintenance organization

Front 28

refers to the amount of money that an individual or business must pay for an insurance plan.

Back 28

Premium

Front 29

amount that the policy-holder or their sponsor (i.e. an employer) pays to the health plan to purchase health coverage.

Back 29

Premium

Front 30

the amount that the insured must pay out-of-pocket before the health insurer pays its share.

Back 30

Deductible

Front 31

fixed, pre-arranged monthly payments made to a physician, clinic, or hospital per patient enrolled in a health plan, or per capita, by a health insurance company.

Back 31

Capitation

Front 32

T/F

All prescription drug benefit plans have deductible

Back 32

FALSE

Front 33

responsible for routing prescription information from the pharmacy management software, ensuring that it conforms to NCPDP standards, and routing it to the pharmacy benefit manager.

Back 33

Switch vendor

Front 34

types of co-payment arrangement requires a set co-pay regardless of the medication received and its cost?

Back 34

Flst rate copay

Front 35

flat fee that a patient must pay to the pharmacy at the time a medication is dispensed.

Back 35

Copay

Front 36

produced by Micromedex, a healthcare brand of Truven Health Analytics. Its purpose is to allow comprehensive access to current and accurate drug pricing information, such as the average wholesale price (AWP) and suggested retail price of medications. RED BOOK has information for over 200,000 prescription and over-the-counter drugs, nutraceuticals, and bulk chemicals.

Back 36

Red book

Front 37

refers to the average purchase price of a medication at the wholesale level.

Back 37

average wholesale price (AWP)

Front 38

types of economic analysis studies the perceived benefit of a medication versus its cost?

Back 38

cost-benefit analysis

Front 39

Back 39

Front 40

When billing a third-party provider, which relationship holder code should be selected for a patient that is the spouse of the primary cardholder?

Back 40

02

Front 41

refers to the process that requires a prescriber to obtain approval from a patient’s insurance company before a specific medication can be dispensed.

Back 41

Prior authotization

Front 42

Drug coupon cards for specific medications are provided by

Back 42

Manufacturers

Front 43

an alphanumeric number defined by a pharmacy benefit manager that appears on a health insurance card and is used as a secondary identifier for insurance claims?

Back 43

processor control number (PCN)

Front 44

extra health insurance that covers the gap in the Medicare program coverage.

Back 44

Medigap

Front 45

DAW codes should be used if no product selection is indicated?

Back 45

DAW 0

Front 46

code is an instruction regarding substitution of generic equivalents or order to dispense the specific prescribed medication as written by the prescriber .

Back 46

DAW (Dispense as Written)

Front 47

DAW # means that no product selection is indicated.

Back 47

DAW 0

Front 48

DAW # means substitution not allowed by prescriber

Back 48

DAW 1

Front 49

DAW # states substitution allowed - patient requested the brand product be dispensed,

Back 49

DAW 2

Front 50

DAW # indicates substitution allowed - pharmacist selected product dispensed.

Back 50

DAW 3

Front 51

National Provider Identifier (NPI) is issued by

Back 51

CMS (Centers for Medicare and Medicaid Services).

Front 52

required by an insurance company when processing a prescription claim.

Back 52

patient’s name, identification number, and medication dosage

Front 53

Back 53

Front 54

refers to the process of determining which insurance coverage should be primary, secondary, etc.

Back 54

Coordination benefits

Front 55

following DAW codes should be selected if the prescriber indicates that a generic substitution is permitted, but the generic product is temporarily unavailable so the brand product is dispensed instead?

Back 55

DAW 8

Front 56

refers to the act of processing an insurance claim or bill.

Back 56

Adjudication

Front 57

initial step that should be taken if a “Refill Too Soon” alert occurs when billing an insurance company for a prescription?

Back 57

verify that the correct days supply was entered.

Front 58

codes are used for billing medication therapy management (MTM) services provided by a pharmacist?

Back 58

CPT codes

Front 59

steps should be performed if a “Patient Not Eligible” alert occurs when billing an insurance company for a prescription?

Back 59

Verifying a patient’s name, date of birth, and person code, and checking that the correct insurance company is being billed

Front 60

Back 60

Front 61

a unique 10-digit identification number issued to health care providers to transmit health information.

Back 61

National Provider Identifier (NPI)

Front 62

a six-digit number that appears on a health insurance card and is used to identify a specific plan from a carrier.

Back 62

bank identification number (BIN)

Front 63

refers to the actual cost that a pharmacy paid for a medication.

Back 63

actual acquisition cost (AAC)

Front 64

insurance is provided by or subsidized by the government?

Back 64

Public insurance

Front 65

When billing a third-party provider, which of the following relationship holder codes is usually selected for a patient that is a child of the primary cardholder?

Back 65

03

Front 66

Back 66

Front 67

organization that developed rejection codes that are used when billing a third-party payer.

Back 67

NCPDP

Front 68

Back 68

Front 69

What is NCPDP

Back 69

National Council for Prescription Drug Programs (NCPDP) – lead transformation in the pharmacy services sector by creating and promoting standards for electronic healthcare transactions

Front 70

Tasks of NCPDP

Back 70

• Real-time claims adjudication, eligibility and benefit verification, real-time ordering by the physician, and sharing of medication history

Front 71

How is HMO differ with other health care plan?

Back 71

cost and choice • You choose one primary care physician and all of your health care services go through that physician

• Typically has lower monthly premiums with lower copays and coinsurance with no out-of- network coverage except in the case of a true emergency

• Has their own network of doctors, hospitals and other healthcare provides who have agreed to accept payment at a certain level for any services they provide

Front 72

-You choose one primary care physician and all of your health care services go through that physician

Back 72

HMO

Front 73

-Typically has lower monthly premiums with lower copays and coinsurance with no out-of- network coverage except in the case of a true emergency

Back 73

HMO

Front 74

-• Has their own network of doctors, hospitals and other healthcare provides who have agreed to accept payment at a certain level for any services they provide

Back 74

HMO

Front 75

PPO definition

Back 75

Preferred Provider Organization (PPO) •More flexibility offered in selecting a doctor or hospital and sometimes covers the costs and visits to out-of-network providers

• You do not need a primary care physician and are able to go to any health care professional you want without a referral

•The majority of companies that offer health insurance benefits to employees offer PPO plans

Front 76

-•More flexibility offered in selecting a doctor or hospital and sometimes covers the costs and visits to out-of-network providers • You do not need a primary care physician and are able to go to any health care professional you want without a referral

Back 76

PPO

Front 77

Who provides health coverage through Medicare, Medicaid, the Children’s Health Insurance Program (CHIP) and the Health Insurance Marketplace

Back 77

Centers for Medicare and Medicaid Services (CMS)

Front 78

Task of Centers for Medicare and Medicaid Services (CMS)

Back 78

-Provides health coverage through Medicare, Medicaid, the Children’s Health Insurance Program (CHIP) and the Health Insurance Marketplace

- Provides access to high quality care and improved health at lower costs

- CMS is part of the Department of Health and Human Services (HHS)

Front 79

Who are eligible for MEDICARE

Back 79

Eligibility: 65 or older, younger people with disabilities, people with end stage renal disease.

Front 80

Who are eligible for Medicaid

Back 80

– state funded, low-income families and children, pregnant women, elderly and people with disabilities. Some states include dental services

Front 81

Eligible for Tricare

Back 81

Eligibility: uniformed service members and their families, national guard/reserve members and their families, survivors, former spouses, medal of honor recipients and their families and others registered in the defense enrollment eligibility reporting system (DEERS).

Front 82

MEDICARE PART A

Back 82

-helps cover inpatient care in hospitals, critical access hospitals, skilled nursing facilities (not custodial or long-term care), hospice care and some home health care if certain conditions are met

- if you (or your spouse) did not pay Medicare taxes while you worked and you are age 65 and older and a citizen or permanent resident of the United States, you may be able to buy Part A

- if you do not qualify for premium free Part A, the standard premium is $458 each month if you paid Medicare taxes for less than 30 quarters but if you paid Medicare taxes for 30-39 quarters the standard premium is $252 each month

Front 83

MEDICARE PART B

Back 83

Covers 2 types of services: ­ Medically necessary services – services or supplies that are needed to diagnose or treat your medical condition and that meet accepted standards of medical practice

­ Preventative services – health care to prevent illness or detect it at an early stage, when treatment is most likely to work best - Examples of coverage: ­ Clinical research, ambulance services, durable medical equipment, mental health (inpatient, outpatient, partial hospitalization), limited outpatient prescription drugs

- Coverage is based on 3 main factors: ­ Federal and state laws, national coverage decisions made by Medicare about whether something is covered, and local coverage decisions made by companies in each state that process claims for Medicare

- Premium amount is $144.60 each month

Front 84

MEDICARE PART C

Back 84

all in one alternative to Original Medicare (part A, B and usually D) – Original Medicare exists even if you buy up

- the buy up for Part C depends on several different factors and is very similar to regular private insurance options

- offered by private companies approved by Medicare

- plans may have lower out of pocket costs than Original Medicare

- typically will need to use doctors within the plans network

- typically have access to additional benefits that Original Medicare does not cover such as vision, hearing, and dental

Front 85

Another term for Medicare Part A,B,C,D

Back 85

A Hospital Insurance

B Medical Insurance

C Medical advantage

D Rx Drug

Front 86

MEDICARE PART D

Back 86

Each plan that offers prescription drug coverage through Medicare Part D must give at least a standard level of coverage set by Medicare Part D premiums are based on income

­ If your income is above a certain limit, you will pay an income-related monthly adjustment amount in addition to your plan premium ­ Premiums are typically deducted from your Social Security benefits check

­ Late enrollment penalty could apply if, for any continuous period of 63 days or more after your Initial Enrollment Period is over, you go without a Part C or D plan or creditable prescription drug coverage

­ Penalty is calculated by multiplying 1% of the “national base beneficiary premium” ($32.74 in 2020) time the number of full, uncovered months you did not have Part D or creditable coverage and added to your monthly premium

2 ways to get Part D coverage ­ Buy up option ­ Medicare Advantage Plan (Part C)

Front 87

What is 340B program?

Back 87