Pharmacy Pharmacy Billing and Insurance

Question 1

What does the DAW code '1' indicate on a prescription?

Accepted Answer

Dispense as written — brand medically necessary

Answer

DAW 1 means the prescriber has indicated that the brand-name drug is medically necessary and generic substitution is not permitted.

Question 2

Which field on a pharmacy claim identifies the prescriber's DEA number?

Accepted Answer

Field 411-DB

Answer

NCPDP field 411-DB is the standard field used to transmit the prescriber's DEA number on a pharmacy claim.

Question 3

A patient's insurance plan has a $300 deductible that has not been met. The medication costs $120. What does the patient owe?

Accepted Answer

$120

Answer

Because the deductible has not been met, the patient must pay the full medication cost of $120 out-of-pocket.

Question 4

What is a formulary in the context of pharmacy insurance?

Accepted Answer

A list of drugs covered by an insurance plan

Answer

A formulary is a list of prescription drugs, both generic and brand-name, preferred by a health plan and covered at varying cost-sharing tiers.

Question 5

Which reject code indicates that a patient's prescription benefit has reached its plan limit?

Accepted Answer

76 — Plan limitations exceeded

Answer

Reject code 76 means the patient has exceeded the benefit maximum set by their insurance plan for a specific drug or category.

Pharmacy Practice Test