CNPR Managed Care & Reimbursement 1 — Questions and Answers
Question 1: What is a formulary in the context of managed care?
- A legal document required by the FDA for drug approval
- A list of prescription drugs covered by a health plan, organized by tiers (Correct answer)
- A physician's prescription pad used in hospitals
- A database maintained by the CDC tracking drug adverse events
Correct answer: A list of prescription drugs covered by a health plan, organized by tiers
A formulary is a list of preferred prescription drugs covered by a health plan, typically organized into cost tiers that determine patient out-of-pocket costs.
Question 2: What does the abbreviation PBM stand for in the pharmaceutical industry?
- Pharmaceutical Benefits Manager
- Pharmacy Benefit Manager (Correct answer)
- Prescriber Billing Monitor
- Patient Benefit Mediator
Correct answer: Pharmacy Benefit Manager
PBM stands for Pharmacy Benefit Manager, a third-party administrator that manages prescription drug benefits on behalf of health insurers, employers, and government programs.
Question 3: Prior authorization (PA) in managed care requires that:
- A patient must obtain approval from their pharmacist before seeing a doctor
- A prescriber must get approval from a payer before a specific drug will be covered (Correct answer)
- A pharmaceutical rep must notify the FDA before detailing a new product
- A drug manufacturer must file a report with CMS before launching a product
Correct answer: A prescriber must get approval from a payer before a specific drug will be covered
Prior authorization requires a prescriber to obtain approval from the health plan before a specific drug is covered, ensuring medical necessity and cost management.
Question 4: Step therapy requires patients to:
- Try a less expensive or preferred drug before coverage is granted for a higher-tier drug (Correct answer)
- Visit a specialist before a primary care physician can prescribe
- Complete a physical therapy program before receiving medication
- Fill prescriptions in 90-day supplies before switching to monthly fills
Correct answer: Try a less expensive or preferred drug before coverage is granted for a higher-tier drug
Step therapy is a cost-management protocol requiring patients to try less costly or preferred drug options first before the plan will cover a more expensive alternative.
Question 5: On a typical three-tier formulary, which tier carries the LOWEST patient copay?
- Tier 3 — brand-name non-preferred drugs
- Tier 2 — preferred brand-name drugs
- Tier 1 — generic drugs (Correct answer)
- Tier 4 — specialty drugs
Correct answer: Tier 1 — generic drugs
Tier 1 typically consists of generic drugs and carries the lowest copay, as generics are the most cost-effective option for the payer and the patient.
Question 6: Medicare Part D is designed to cover:
- Inpatient hospital services for Medicare beneficiaries
- Outpatient physician services and diagnostic tests
- Prescription drug benefits for Medicare-eligible individuals (Correct answer)
- Long-term nursing home care for elderly patients
Correct answer: Prescription drug benefits for Medicare-eligible individuals
Medicare Part D is the voluntary outpatient prescription drug benefit program available to all Medicare-eligible individuals, administered through private insurance plans.
Question 7: A co-pay in a prescription drug benefit plan is best described as:
- The total annual amount a patient must pay before insurance begins covering costs
- A fixed dollar amount a patient pays for a prescription at the point of sale (Correct answer)
- The percentage of drug costs shared between the patient and the insurer
- A penalty fee charged when a patient fills a prescription out of network
Correct answer: A fixed dollar amount a patient pays for a prescription at the point of sale
A co-pay is a fixed dollar amount (e.g., $10 or $30) that a patient pays each time they fill a prescription, regardless of the drug's total cost.
CNPR Managed Care & Reimbursement 1
What is a formulary in the context of managed care?