Practice Test Geeks(CNPR) Certified National Pharmaceutical Representative Practice Test
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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.

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  1. What is a formulary in the context of managed care?

    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.

  2. What does the abbreviation PBM stand for in the pharmaceutical industry?

    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.

  3. Prior authorization (PA) in managed care requires that:

    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.

  4. Step therapy requires patients to:

    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.

  5. On a typical three-tier formulary, which tier carries the LOWEST patient copay?

    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.

  6. Medicare Part D is designed to cover:

    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.

  7. A co-pay in a prescription drug benefit plan is best described as:

    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.