PTCE PTCE Billing and Reimbursement 2 — Questions and Answers
Question 1: What is the 'usual and customary' (U&C) price in pharmacy billing?
- The maximum price set by the FDA
- The price a pharmacy charges cash-paying customers (Correct answer)
- The price negotiated with a wholesaler
- The price printed on the manufacturer's label
Correct answer: The price a pharmacy charges cash-paying customers
The U&C price is the standard cash price a pharmacy charges, and insurance plans typically reimburse the lower of the U&C or contracted rate.
Question 2: What does 'days supply' mean in the context of a prescription claim?
- The number of days a drug remains stable after opening
- The number of days the dispensed quantity is expected to last (Correct answer)
- The number of days until the prescription expires
- The number of days a prior authorization is valid
Correct answer: The number of days the dispensed quantity is expected to last
Days supply is calculated by dividing the dispensed quantity by the daily dose and is required on insurance claims to prevent early refills.
Question 3: What does co-insurance mean in pharmacy benefits?
- Having two insurance plans simultaneously
- A fixed dollar amount paid per prescription
- A percentage of the drug cost the patient pays after meeting the deductible (Correct answer)
- A discount card used at the pharmacy
Correct answer: A percentage of the drug cost the patient pays after meeting the deductible
Co-insurance is the patient's percentage share of the drug cost (e.g., 20%) after their deductible has been met, as opposed to a fixed copay.
Question 4: What does claim rejection code '75' typically indicate?
- Patient not eligible
- Prior authorization required (Correct answer)
- Drug not covered on formulary
- Refill too soon
Correct answer: Prior authorization required
Rejection code 75 means the insurance requires a prior authorization before it will reimburse for the prescribed medication.
Question 5: What is a drug formulary tier system used for?
- Ranking pharmacies by quality
- Classifying drugs by strength
- Determining the patient's copay level based on drug category (Correct answer)
- Organizing drugs alphabetically
Correct answer: Determining the patient's copay level based on drug category
Formulary tiers assign drugs to categories (e.g., generics, preferred brands, non-preferred brands) with increasing copay amounts at higher tiers.
Question 6: What is a pharmacy deductible?
- A fee charged to activate pharmacy benefits
- The amount a patient must pay out-of-pocket before insurance begins covering prescriptions (Correct answer)
- A penalty for using an out-of-network pharmacy
- The maximum amount an insurance plan will pay annually
Correct answer: The amount a patient must pay out-of-pocket before insurance begins covering prescriptions
A deductible is the set amount a patient must spend on covered medications before the insurance plan starts paying its share.
PTCE PTCE Billing and Reimbursement 2
What is the 'usual and customary' (U&C) price in pharmacy billing?