Pharmacy Billing and Insurance Flashcards
6 cards from real Pharmacy practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 Pharmacy Billing and Insurance flashcards as text
What is the meaning of 'usual and customary' (U&C) price in pharmacy billing?
Answer: The lowest price a pharmacy charges any customer for a drug on that day
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.
What does a 'refill too soon' rejection mean?
Answer: The patient is attempting to refill before the allowed refill date per the plan
A refill-too-soon rejection occurs when a patient tries to refill a prescription before the insurance plan's allowed refill window has elapsed.
Which law mandates that pharmacy benefit information be clearly disclosed to Medicare Part D enrollees?
Answer: Medicare Modernization Act (MMA) of 2003
The Medicare Modernization Act of 2003 established Medicare Part D and requires insurance plans to clearly disclose formulary and benefit information to enrollees.
A patient presents a manufacturer coupon that reduces their brand-name drug co-pay to $0. What concern does this raise?
Answer: Accumulation toward the deductible may not be credited by the insurer
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.
What identifier is used to uniquely identify a pharmacy when submitting insurance claims?
Answer: NCPDP Provider ID
The NCPDP Provider ID (also called the NCPDP number) is the unique 7-digit identifier required to submit electronic pharmacy claims to insurance payers.
What does the term 'step therapy' mean in pharmacy insurance?
Answer: Requiring a patient to try lower-cost drugs before approving a preferred or expensive drug
Step therapy is a coverage policy requiring patients to try and fail on one or more preferred (usually lower-cost) drugs before the insurer will cover a more expensive medication.