CNPR Managed Care & Reimbursement 2 — Questions and Answers
Question 1: Which managed care plan type restricts members to a network of providers and requires referrals to see specialists?
- Preferred Provider Organization (PPO)
- Health Maintenance Organization (HMO) (Correct answer)
- High Deductible Health Plan (HDHP)
- Point of Service (POS) plan
Correct 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.
Question 2: AWP (Average Wholesale Price) in the pharmaceutical industry refers to:
- The price the government mandates for all wholesale drug transactions
- A benchmark price published for prescription drugs, often used in pricing and reimbursement calculations (Correct answer)
- The average price consumers pay at retail pharmacies without insurance
- The price set by the FDA for new drug approvals
Correct 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.
Question 3: Generic substitution allows a pharmacist to:
- Substitute a brand-name drug with a therapeutic alternative from a different drug class
- Dispense a therapeutically equivalent generic drug in place of a prescribed brand-name drug (Correct answer)
- Substitute one controlled substance for another with the prescriber's written consent
- Replace a patient's medication with an OTC equivalent without physician approval
Correct 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.
Question 4: What is the primary difference between Medicare and Medicaid?
- Medicare covers prescription drugs only; Medicaid covers medical services only
- Medicare is age/disability-based federal insurance; Medicaid is income-based state-federal insurance (Correct answer)
- Medicare is administered by states; Medicaid is administered by the federal government
- Medicare applies only to veterans; Medicaid applies to all citizens
Correct 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.
Question 5: Specialty pharmacies are most commonly used for drugs that:
- Are available over the counter and require no prescription
- Are inexpensive generics dispensed in 90-day supplies
- Are complex, high-cost biologics or specialty medications requiring special handling and monitoring (Correct answer)
- Are first-line antibiotics prescribed for common infections
Correct 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.
Question 6: Drug Utilization Review (DUR) is a program used by payers to:
- Evaluate the commercial viability of new pharmaceutical products before launch
- Review prescribing patterns to identify safety issues, inappropriate use, or cost savings opportunities (Correct answer)
- Audit pharmaceutical sales representatives' call activity
- Assess clinical trial data submitted for FDA approval
Correct 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.
Question 7: In managed care, rebates are typically paid by drug manufacturers to:
- Patients to reduce out-of-pocket costs at the pharmacy counter
- The FDA as a fee for expedited drug review
- Pharmacy Benefit Managers or health plans in exchange for favorable formulary placement (Correct answer)
- Prescribers to incentivize higher prescribing volume
Correct 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.
CNPR Managed Care & Reimbursement 2
Which managed care plan type restricts members to a network of providers and requires referrals to see specialists?