AHIP Medicare Part D Prescription Drug Plans 2 — Questions and Answers
Question 1: A Part D plan's tier structure typically places generic drugs in which tier?
- Tier 4 (Specialty)
- Tier 3 (Preferred Brand)
- Tier 1 (lowest cost-sharing) (Correct answer)
- Tier 2 (Non-Preferred)
Correct answer: Tier 1 (lowest cost-sharing)
Generics are typically placed in Tier 1, which has the lowest cost-sharing, encouraging use of lower-cost alternatives.
Question 2: What is 'step therapy' in a Medicare Part D plan?
- A graduated deductible that decreases over time
- A requirement to try lower-cost drugs before a plan covers a preferred drug (Correct answer)
- A multi-step enrollment process
- Tiered cost-sharing based on pharmacy type
Correct answer: A requirement to try lower-cost drugs before a plan covers a preferred drug
Step therapy requires beneficiaries to try one or more alternative (usually less expensive) drugs before the plan will cover the originally prescribed medication.
Question 3: Which of the following is a beneficiary's right when a Part D plan denies coverage of a drug?
- No recourse; plan decisions are final
- Request an exception or file an appeal (Correct answer)
- Only request a formulary change at the next plan year
- Switch pharmacies to override the denial
Correct answer: Request an exception or file an appeal
Beneficiaries have the right to request a formulary exception or appeal a coverage determination if a drug is denied.
Question 4: A 'Medication Therapy Management' (MTM) program in Part D is designed to:
- Reduce plan premiums for healthy members
- Help beneficiaries with complex drug regimens use medications safely and effectively (Correct answer)
- Limit the number of prescriptions a member can fill per month
- Replace physician prescribing authority
Correct answer: Help beneficiaries with complex drug regimens use medications safely and effectively
MTM programs are designed to improve outcomes for beneficiaries with multiple chronic conditions and complex medication regimens.
Question 5: Stand-alone Part D Prescription Drug Plans (PDPs) are available to beneficiaries enrolled in:
- Medicare Advantage plans only
- Original Medicare (Parts A and/or B) (Correct answer)
- Medicaid only
- TRICARE only
Correct answer: Original Medicare (Parts A and/or B)
Stand-alone PDPs are available to beneficiaries enrolled in Original Medicare to add drug coverage.
Question 6: What is the purpose of CMS's Prescription Drug Plan (PDP) formulary exception process?
- To allow plans to remove drugs from their formulary at any time
- To allow beneficiaries to request coverage for a non-formulary drug when medically necessary (Correct answer)
- To permit pharmacies to substitute brand drugs with generics
- To let plans change cost-sharing tiers mid-year
Correct answer: To allow beneficiaries to request coverage for a non-formulary drug when medically necessary
The exception process allows a beneficiary (or their prescriber) to request that the plan cover a non-formulary drug when there is a medical necessity.
AHIP Medicare Part D Prescription Drug Plans 2
A Part D plan's tier structure typically places generic drugs in which tier?