CNPR Managed Care & Reimbursement

Question 1

What is a formulary in the context of managed care?

Accepted Answer

A list of prescription drugs covered by a health plan, organized by tiers

Answer

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.

Question 2

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

Accepted Answer

Pharmacy Benefit Manager

Answer

PBM stands for Pharmacy Benefit Manager, a third-party administrator that manages prescription drug benefits on behalf of health insurers, employers, and government programs.

Question 3

Prior authorization (PA) in managed care requires that:

Accepted Answer

A prescriber must get approval from a payer before a specific drug will be covered

Answer

Prior authorization requires a prescriber to obtain approval from the health plan before a specific drug is covered, ensuring medical necessity and cost management.

Question 4

Step therapy requires patients to:

Accepted Answer

Try a less expensive or preferred drug before coverage is granted for a higher-tier drug

Answer

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.

Question 5

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

Accepted Answer

Tier 1 — generic drugs

Answer

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.

(CNPR) Certified National Pharmaceutical Representative Practice Test

(CNPR) Certified National Pharmaceutical Representative Practice Test

CNPR Managed Care & Reimbursement