CSP - Certified Specialty Pharmacist Payer and Reimbursement Models Questions and Answers

Question 1

A patient with rheumatoid arthritis receives a physician-administered intravenous biologic in a hospital outpatient clinic.
The specialty pharmacy supplies the medication to the clinic.
Under which benefit is this drug MOST likely to be reimbursed, and what is the common payment methodology used by Medicare for it?

Accepted Answer

Medical Benefit; based on Average Sales Price (ASP) plus a percentage.

Answer

Pharmacy Benefit; based on Average Wholesale Price (AWP) minus a percentage.

Answer

Medical Benefit; based on a flat per-member-per-month capitation fee.

Answer

Pharmacy Benefit; based on Wholesale Acquisition Cost (WAC) plus a dispensing fee.

Question 2

Which of the following best describes a value-based reimbursement model for a specialty medication?

Accepted Answer

The health plan's payment for a medication is partially dependent on the drug achieving specific, pre-defined clinical outcomes for the patient.

Answer

The pharmacy is paid a fixed fee for each prescription dispensed, regardless of the drug's cost.

Answer

The manufacturer provides a rebate to the payer based on the volume of the drug sold.

Answer

The patient's copay is adjusted based on their income level and ability to pay.

Question 3

A patient's commercial insurance plan utilizes a 'copay accumulator' program. The patient uses a manufacturer's copay card, which covers their $400 monthly cost for a specialty drug. What is the primary consequence of this program for the patient?

Accepted Answer

The $400 paid by the manufacturer will not count toward the patient's annual deductible or out-of-pocket maximum.

Answer

The patient will reach their annual deductible faster than anticipated.

Answer

The manufacturer's payment will be rejected by the specialty pharmacy.

Answer

The health plan will reimburse the manufacturer for the $400 payment.

Question 4

A specialty pharmacy contracts with a Federally Qualified Health Center (FQHC) to dispense medications to its eligible patients. This arrangement allows the FQHC to generate savings to support its services. Which federal program enables this?

Accepted Answer

The 340B Drug Pricing Program.

Answer

The Medicare Part D Coverage Gap Discount Program.

Answer

The Medicaid Drug Rebate Program.

Answer

The Prescription Drug Marketing Act.

Question 5

A Pharmacy Benefit Manager (PBM) is designing its formulary for a competitive therapeutic class, such as inflammatory conditions. To control spending and steer patients towards its preferred biologic agent, which combination of strategies is the PBM most likely to employ?

Accepted Answer

Negotiating higher rebates for a preferred product and requiring step therapy through a non-preferred agent first.

Answer

Offering the same low copay for all drugs in the class to promote patient choice.

Answer

Eliminating all prior authorization requirements for the entire class.

Answer

Mandating that all drugs be purchased through the 'buy-and-bill' process.

Question 6

A patient is prescribed an oral oncolytic that is covered under their pharmacy benefit. The reimbursement that the specialty pharmacy receives from the PBM is most commonly based on which of the following models?

Accepted Answer

A discount off a benchmark price, such as Average Wholesale Price (AWP) or Wholesale Acquisition Cost (WAC), plus a dispensing fee.

Answer

A bundled payment covering the drug, counseling, and all ancillary supplies.

Answer

A per-diem rate for each day the patient is on therapy.

Answer

Average Sales Price (ASP) plus a 6% administration fee.