CSP Intake and Patient Onboarding 2 — Questions and Answers
Question 1: A specialty pharmacy receives an e-prescription for a limited distribution drug (LDD) that the pharmacy is not in the manufacturer's network to dispense. What is the most appropriate intake action?
- Hold the prescription until the manufacturer adds the pharmacy to its network
- Order the drug from a wholesaler and dispense it anyway
- Return the prescription to the prescriber with no further communication
- Transfer the prescription to an in-network specialty pharmacy and notify the prescriber and patient (Correct answer)
Correct answer: Transfer the prescription to an in-network specialty pharmacy and notify the prescriber and patient
LDDs can only be dispensed by pharmacies in the manufacturer's network, so prompt transfer with notification prevents delays in therapy.
Question 2: During a benefits investigation, the intake team learns a self-administered specialty drug is covered under the patient's medical benefit rather than the pharmacy benefit. What does this primarily affect?
- The patient's eligibility for HIPAA protections
- The drug's FDA-approved indication
- How the claim is billed and which authorization process applies (Correct answer)
- Whether the drug requires a REMS program
Correct answer: How the claim is billed and which authorization process applies
Medical versus pharmacy benefit coverage determines the billing pathway (e.g., J-code/CMS-1500 vs. NCPDP) and the payer's prior authorization requirements.
Question 3: A commercially insured patient cannot afford a $3,000 specialty copay. Which resource is typically the first option to check for this patient?
- Medicaid spend-down program
- State pharmaceutical assistance program for seniors
- Medicare Extra Help (LIS)
- Manufacturer copay assistance card (Correct answer)
Correct answer: Manufacturer copay assistance card
Manufacturer copay cards are generally available to commercially insured patients and can sharply reduce out-of-pocket costs.
Question 4: Why are manufacturer copay coupons generally prohibited for patients enrolled in Medicare Part D?
- Medicare Part D does not cover specialty drugs
- HIPAA prohibits sharing Medicare data with manufacturers
- They may violate the federal Anti-Kickback Statute (Correct answer)
- The FDA bans copay coupons for biologics
Correct answer: They may violate the federal Anti-Kickback Statute
The OIG considers manufacturer copay assistance for federal health program beneficiaries a potential inducement under the Anti-Kickback Statute.
Question 5: Which item is typically NOT required on a complete specialty pharmacy referral intake form?
- Diagnosis code (ICD-10)
- Prescriber signature and NPI
- Insurance information
- The patient's preferred grocery store (Correct answer)
Correct answer: The patient's preferred grocery store
A complete referral needs clinical, prescriber, and insurance data, but unrelated personal preferences are not required.
Question 6: A prior authorization for a specialty drug is denied for 'step therapy not met.' What is the most appropriate next intake step?
- Dispense the drug and bill the patient cash
- Switch the patient to a different drug without prescriber input
- Cancel the referral permanently
- Work with the prescriber to document prior failed therapies or submit a step-therapy exception (Correct answer)
Correct answer: Work with the prescriber to document prior failed therapies or submit a step-therapy exception
Step-therapy denials can often be overturned with documentation of previous trials, contraindications, or an exception request.
Question 7: During the patient welcome call, which topic is most essential to cover before the first shipment?
- Explaining the manufacturer's stock price
- Reviewing the pharmacy's annual revenue
- Confirming delivery address, date, and someone available to receive cold-chain shipments (Correct answer)
- Discussing the prescriber's malpractice history
Correct answer: Confirming delivery address, date, and someone available to receive cold-chain shipments
Confirming delivery logistics prevents lost or temperature-compromised shipments of high-cost medications.
