Pharmacy Pharmacy Billing and Insurance 3

Question 1

What is the meaning of 'usual and customary' (U&C) price in pharmacy billing?

Accepted Answer

The lowest price a pharmacy charges any customer for a drug on that day

Answer

The usual and customary price is the cash price a pharmacy charges to the general public for a drug, which insurers compare against their reimbursement rates.

Question 2

What does a 'refill too soon' rejection mean?

Accepted Answer

The patient is attempting to refill before the allowed refill date per the plan

Answer

A refill-too-soon rejection occurs when a patient tries to refill a prescription before the insurance plan's allowed refill window has elapsed.

Question 3

Which law mandates that pharmacy benefit information be clearly disclosed to Medicare Part D enrollees?

Accepted Answer

Medicare Modernization Act (MMA) of 2003

Answer

The Medicare Modernization Act of 2003 established Medicare Part D and requires insurance plans to clearly disclose formulary and benefit information to enrollees.

Question 4

A patient presents a manufacturer coupon that reduces their brand-name drug co-pay to $0. What concern does this raise?

Accepted Answer

Accumulation toward the deductible may not be credited by the insurer

Answer

Many insurers do not allow coupon payments to count toward the patient's deductible or out-of-pocket maximum, which can disadvantage patients over time.

Question 5

What identifier is used to uniquely identify a pharmacy when submitting insurance claims?

Accepted Answer

NCPDP Provider ID

Answer

The NCPDP Provider ID (also called the NCPDP number) is the unique 7-digit identifier required to submit electronic pharmacy claims to insurance payers.

Pharmacy Practice Test

Pharmacy Practice Test

Pharmacy Pharmacy Billing and Insurance 3