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 does the DAW code '1' indicate on a prescription?
Answer: Dispense as written — brand medically necessary
DAW 1 means the prescriber has indicated that the brand-name drug is medically necessary and generic substitution is not permitted.
Which field on a pharmacy claim identifies the prescriber's DEA number?
Answer: Field 411-DB
NCPDP field 411-DB is the standard field used to transmit the prescriber's DEA number on a pharmacy claim.
A patient's insurance plan has a $300 deductible that has not been met. The medication costs $120. What does the patient owe?
Answer: $120
Because the deductible has not been met, the patient must pay the full medication cost of $120 out-of-pocket.
What is a formulary in the context of pharmacy insurance?
Answer: A list of drugs covered by an insurance plan
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.
Which reject code indicates that a patient's prescription benefit has reached its plan limit?
Answer: 76 — Plan limitations exceeded
Reject code 76 means the patient has exceeded the benefit maximum set by their insurance plan for a specific drug or category.
A co-pay assistance card cannot be used with which type of plan?
Answer: Federal or state government insurance such as Medicare or Medicaid
Federal anti-kickback laws prohibit the use of manufacturer co-pay assistance cards with federally funded insurance programs like Medicare and Medicaid.