CVS CVS Assessment Insurance and Prescription Processing Questions and Answers 1 — Questions and Answers
Question 1: What information is typically required to process a prescription through insurance at CVS?
- Customer's email address and birth year only
- BIN, PCN, group number, and member ID from the insurance card (Correct answer)
- The prescriber's office phone number and NPI
- The customer's Social Security number and driver's license
Correct answer: BIN, PCN, group number, and member ID from the insurance card
The BIN, PCN, group number, and member ID are the four fields the pharmacy system needs to submit a claim to the insurer.
Question 2: A claim is rejected with the message 'refill too soon.' This most commonly means:
- The prescription has expired
- The insurance will not pay because the previous fill has not run out yet based on days-supply calculations (Correct answer)
- The prescriber did not authorize refills
- The drug is not covered under the patient's plan
Correct answer: The insurance will not pay because the previous fill has not run out yet based on days-supply calculations
Insurers track days-supply to enforce fill intervals and will reject early refills until a set percentage of the prior supply is used.
Question 3: When a drug is rejected as 'non-formulary,' the best next step is to:
- Tell the patient there is nothing that can be done
- Notify the pharmacist, who may contact the prescriber about a formulary alternative or prior authorization (Correct answer)
- Bill the claim to a secondary insurance automatically
- Substitute a different drug without prescriber knowledge
Correct answer: Notify the pharmacist, who may contact the prescriber about a formulary alternative or prior authorization
Non-formulary rejections require clinical intervention—either a therapeutic substitution authorized by the prescriber or a prior authorization.
Question 4: What is a 'prior authorization' (PA) in the context of prescription insurance?
- The patient's consent to fill the prescription
- A process where the insurer requires medical justification before approving coverage for a drug (Correct answer)
- A prescriber's permission to dispense a controlled substance
- CVS corporate approval to stock a high-cost medication
Correct answer: A process where the insurer requires medical justification before approving coverage for a drug
A PA requires the prescriber to submit clinical evidence to the insurer proving the drug is medically necessary.
Question 5: If a patient wants to pay cash instead of using insurance for a prescription, what should the technician do?
- Refuse because CVS requires all prescriptions to be billed to insurance
- Process it as a cash transaction at the applicable price and inform the patient of any discount programs (Correct answer)
- Bill insurance first and apply cash as a secondary payment
- Ask the patient why they are not using insurance before proceeding
Correct answer: Process it as a cash transaction at the applicable price and inform the patient of any discount programs
Patients have the right to pay out-of-pocket; technicians should process the cash transaction and mention programs like CVS discount pricing.
Question 6: Days supply on a prescription is important to calculate accurately because it affects:
- Only the pharmacist's verification step
- Insurance reimbursement, refill timing, and adherence monitoring (Correct answer)
- The font size printed on the label
- Whether a child-resistant cap is required
Correct answer: Insurance reimbursement, refill timing, and adherence monitoring
Days supply drives insurance claim adjudication, determines when a refill is due, and feeds into adherence tracking programs.
CVS CVS Assessment Insurance and Prescription Processing Questions and Answers 1
What information is typically required to process a prescription through insurance at CVS?