INSURANCE PT II

Question 1

prior authorization

Answer 1

certain medications may need approval from your health insurance carrier, before they’re covered.

• when prior auth is needed: pharmacy have to notify the Dr. that prior auth is needed & the Dr. have to contact the insurance company to complete the prior auth.

Question 2

What are some reasons an insurance claim might be rejected?

Answer 2

• NDC not covered
- try to bill an insurance plan for meds that are not on the formulary (OTC)

• Refill too soon
• Therapeutic duplication
• Drug-Drug interaction
• Look-alike/sound-alike
• Dose to high

Question 3

plan limitation

Answer 3

some insurance plans limit the quantity of a medication they will cover

Question 4

Pharmacy Benefits Manager (PBM)

Answer 4

is a third-party administrator that manage prescription drug benefits on behalf of health insurers

• PMBs enter into contracts w/ pharmacies, develop formularies, and process prescription drug claims

Question 5

Medication Assistance Program (MAP)

Answer 5

is a program that provides financial help for patients that cannot afford their medications

Question 6

How do prescription drug coupons work?

Answer 6

they must be billed like insurance plans

• cannot be used by patients enrolled in gov. prescription drug programs ex: Medicaid/Medicare Part D

Question 7

coordination of benefits

Answer 7

process by which a health insurance company determines if it should be the primary or secondary payer of medical claims for a patient who has coverage from more than one health insurance policy

Question 8

home health care

Answer 8

delivery of health care directly in the patients home.

• Usually this involves a nurse visiting the patients home periodically for monitoring & administering meds.

Question 9

home infusion pharmacy

Answer 9

is a pharmacy that prepares & delivers IV meds for administration in the patients home