CPhT Insurance and Billing Flashcards

What is the purpose of a drug utilization review (DUR) in pharmacy?

Answer: To identify potential drug interactions, duplications, or contraindications during dispensing

DUR is a process that evaluates prescription drug use to identify and prevent drug interactions, therapeutic duplications, and other medication-related problems.

What does a mail-order pharmacy typically offer compared to retail pharmacy?

Answer: 90-day supplies at reduced cost for maintenance medications

Mail-order pharmacies typically offer 90-day supplies of maintenance medications at a lower cost compared to retail pharmacies filling 30-day supplies.

What is a specialty pharmacy primarily designed to handle?

Answer: High-cost, complex medications that require special handling or monitoring

Specialty pharmacies focus on high-cost, complex medications such as biologics and specialty drugs that require special storage, handling, and patient monitoring.

What information is typically required from a prescription insurance card to process a claim?

Answer: BIN, PCN, group number, and member ID

A pharmacy insurance card typically contains the BIN, PCN, group number, and member ID needed to process electronic prescription claims.

What option is available when a medication is 'not covered' by a patient's insurance?

Answer: The patient may pay full cash price or ask the prescriber for a covered alternative

When a medication is not covered by insurance, the patient may pay the full cash price, use a discount program, or ask the prescriber for a covered alternative.

What is the PCN number on an insurance card used for?

Answer: Processor Control Number used to route claims within a PBM's system

The PCN (Processor Control Number) works with the BIN to route the pharmacy claim to the correct processor within the PBM's system.