Managed Care & Reimbursement Flashcards
7 cards from real CNPR practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Managed Care & Reimbursement flashcards as text
Which managed care plan type restricts members to a network of providers and requires referrals to see specialists?
Answer: Health Maintenance Organization (HMO)
An HMO requires members to select a primary care physician (PCP) and obtain referrals to see specialists, and generally limits coverage to providers within the plan's network.
AWP (Average Wholesale Price) in the pharmaceutical industry refers to:
Answer: A benchmark price published for prescription drugs, often used in pricing and reimbursement calculations
AWP is a published benchmark price for prescription drugs used as a reference point in pricing negotiations and reimbursement calculations, though it does not reflect actual transaction prices.
Generic substitution allows a pharmacist to:
Answer: Dispense a therapeutically equivalent generic drug in place of a prescribed brand-name drug
Generic substitution allows pharmacists to dispense an AB-rated (therapeutically equivalent) generic version of a brand-name drug, which has the same active ingredient, dosage form, and strength.
What is the primary difference between Medicare and Medicaid?
Answer: Medicare is age/disability-based federal insurance; Medicaid is income-based state-federal insurance
Medicare is a federal health insurance program primarily for people 65 and older or those with qualifying disabilities, while Medicaid is a joint state-federal program for individuals with low income.
Specialty pharmacies are most commonly used for drugs that:
Answer: Are complex, high-cost biologics or specialty medications requiring special handling and monitoring
Specialty pharmacies handle complex, high-cost drugs such as biologics, injectables, and specialty medications that require special storage, handling, patient education, and adherence monitoring.
Drug Utilization Review (DUR) is a program used by payers to:
Answer: Review prescribing patterns to identify safety issues, inappropriate use, or cost savings opportunities
DUR programs review prescribing and dispensing patterns to detect drug interactions, inappropriate use, or opportunities to improve safety, quality, and cost-effectiveness of drug therapy.
In managed care, rebates are typically paid by drug manufacturers to:
Answer: Pharmacy Benefit Managers or health plans in exchange for favorable formulary placement
Manufacturers negotiate rebates paid to PBMs or health plans in return for favorable formulary status (preferred tier placement), which increases patient and prescriber access to their drug.