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 average wholesale price of the drug

Answer

The maximum allowed reimbursement set by the insurer

Answer

The co-pay amount listed on a patient's card

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

The prescription has expired

Answer

The drug requires a new prior authorization

Answer

The prescriber has not authorized refills

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

HIPAA of 1996

Answer

Drug Price Competition Act of 1984

Answer

Omnibus Budget Reconciliation Act of 1990

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

The pharmacy cannot accept manufacturer coupons

Answer

The coupon must be submitted as a secondary claim

Answer

The prescriber must authorize coupon use

Question 5

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

Accepted Answer

NCPDP Provider ID

Answer

DEA number

Answer

State pharmacy license number

Answer

Federal tax ID

Question 6

What does the term 'step therapy' mean in pharmacy insurance?

Accepted Answer

Requiring a patient to try lower-cost drugs before approving a preferred or expensive drug

Answer

A protocol for tapering high-dose opioids

Answer

Incrementally increasing a dose to therapeutic levels

Answer

Switching from brand to generic at each refill