Types of Third Party Programs
Which of the following is the third party in a prescription program?
A. Patient
B. Insurer
C. Physician
D. Pharmacist
What is B
A patient with a 100 deductible is 18.32 short of reaching that deductible. After reaching the deductible, the patient pays 20% as a coinsurance amount. What amount should a pharmacy technician ask the patient to pay when the patient picks up a prescription with a U&C price of 79.44?
WHat is 30.54
Patient pays a specified dollar amount each refill.
What is copayment.
Which of the following examples best explains how a pharmacy computer system ensures proper claim adjudication?
A. Verifies patient eligibility
B. Inserts NDC numbers
C. Maintains inventory of medications
D. Calculates the total amount of purchases
What is A
Which medications are commonly listed on negative formularies?
What is cosmetic purposes, weight control products, experimental meds, parenteral medications other than insulin, most compounded meds.
Which of the following third party plans has the least control over consumer costs?
A. Government plans
B. Managed Care Plans
C. Managed Indemnity Plans
D. Traditional Indemnity Plans
What is D
Patient pays a specified percentage of a prescription. What is that called?
What is coinsurance?
The cost the pharmacy pays for direct purchases
What is direct acquisition cost
Third party insurance approval process.
What is adjudication
Private health benefit programs and government run programs that pay for prescriptions on behalf of patients.
Third Party Programs
If a third party provider wants to have maximum control over costs, which of the following plans should they offer?
A. PPO plan
B. An HMO plan
C. A managed indemnity plan
D. A traditional indemnity plan
Specific dollar amount that must be paid each year.
What is deductible
The estimated price that the state medicaid programs use for reimbursement
What is estimated acquisition cost
A process in which patterns of prescribing, dispensing and using prescription medications are monitored. May be prospective or retrospective.
What is DUR - Drug Utilization Review
A medication that has a generic form available.
Multiple source brand medications
Name the 3 government administered third party payers?
What is tricare, medicaid, and medicare
A pharmacy has a discount agreement with a third party. The pharmacy submits a prescription claim for $173.90. The patient has a copay of 25. The third party reimburses the pharmacy 136.72. What amount (in dollars) should the pharmacy deduct for the discount?
What is 12.18
The average acquisition cost to pharmacy from a wholesaler
What is average acquisition cost
A requirement that specific medications be covered only if approved by the third party payer. Usually prescribers or pharmacists must certify that the medication is medically necessary and superior to less costly alternatives before approval is given to dispense it.
What is prior authorization
Six digit number on an insurance card that the pharmacy uses to identify which insurance provider should receive the claim.
Bank Identification Number (BIN)
Name the 2 types of private managed care plans offered by MCOs.
What is PPO and HMO
After a patient meets a $100 deductible, their covers 80% of their medications and they pay 20%. They have not made any payments toward their deductible. They have a medication to pick up that costs a total of $210. What is the amount in dollars the patient must pay?
What is $122
The average of medication acquisition costs from retail pharmacies
A numerical identifier on an insurance card that may be used to route prescription claims.
What is Processor Control Number (PCN)
A medication that releases its active ingredient at the same rate and in the same amounts as the original medication to produce the same blood levels of the medication.
What is bioequivalent