Prescription Drug Insurance

Question 1

Submitting a claim to a prescription drug insurance plan, requires what type of numbers from the patient’s card?

Answer 1

• bank identification number (BIN)
• processor control number (PCN)
• group number
• ID number

Question 2

What institution has a 6-digit number identification of an accepted electronic pharmaceutical claim?

Answer 2

Bank identification number (BIN)

Question 3

What set of numbers, letters, or combination of both where the supplement information is provided by the BIN called?

Answer 3

Processor control number (PCN)

Question 4

What is an employer group that has a pharmacy plan called?

Answer 4

Group number

Question 5

What is a patient’s single policy where their benefits and terms of coverage vary from each person within the same employer group called?

Answer 5

ID Number

Question 6

What is the type of payment where patient pays full cost of the prescription without the help of any third party payers

Answer 6

Self-pay

Question 7

What is an entity that is outside of the patient-pharmacist relationship that is involved in the financial transaction?

Answer 7

Third party payer

Question 8

Who is the first party within the transaction of a third party payer?

Answer 8

Pharmacy

Question 9

Who is the second party within the transaction of a third party payer?

Answer 9

Patient (or customer)

Question 10

Who is the third party within the transaction of a third party player?

Answer 10

Insurance company (or other party)

Question 11

What type of request is submitted to an insurance company for the payment of a product or service to the provider on the behalf of the patient, if the policy coverage of the product or service terms is specified?

Answer 11

Insurance claim

Question 12

What is the cost of maintaining active insurance coverage called?

Answer 12

Insurance premium

Question 13

What payment must a patient pay out-of-pocket (in addition to the premium) before the insurance benefits are realized called?

Answer 13

Deductible

Question 14

What is the payment by the insured individual according to the terms of the insurance policy called?

Answer 14

Co-payment (or co-pay)

• insurance company pays the remaining expense

Question 15

What type of managed care insurance plan is worked on by forming agreements with healthcare providers?

Answer 15

Health maintenance organization (HMO)

Question 16

What type of managed care insurance plan covers medical expenses that are incurred from healthcare providers and hospital contracts?

Answer 16

Preferred provider organization (PPO)

Question 17

What is a list of drugs that are covered under an insurance plan called?

Answer 17

Insurance formulary

Question 18

What is a preferred drug list list that determines which medications will be maintained on-hand called?

Answer 18

Hospital formulary

Question 19

What type of division of the United States Department of Health and Human Services (DHHS) is responsible for administrating government health insurance programs such as Medicare, Medicaid, and SCHIP (State Children’s Health Insurance Program)?

Answer 19

Centers for medicare and medicaid services (CMS)

Question 20

What type of federally funded health insurance program covers the elderly (age 65 years and older) and people under age 65 with certain disabilities and certain types of kidney called?

Answer 20

Medicare

Question 21

What are the four Medicare parts called?

Answer 21

1) medicare part A
2) medicare part B
3) medicare part C
4) medicare part D

Question 22

Which Medicare part covers hospitalization insurance?

Answer 22

Medicare part A

Question 23

Which Medicare part covers outpatient medical services, durable medical equipment (e.g. wheelchair), prevention services (e.g. immunizations), supplies needed to diagnose and treat medical conditions (e.g. blood glucose test strips and lancets for patients with diabetes), and certain medications that are not self-administered (e.g. oral cancer chemotherapy drugs and immunosuppressants)?

Answer 23

Medicare part B

Question 24

Which Medicare part is optional and allows patients to obtain Medicare part A and B coverage through a private insurance company rather than through the federal government, and is also known as “Medicare Advantage Plans”?

Answer 24

Medicare part C

Question 25

Which Medicare part provides optional prescription drug coverage, and private insurance companies administer it?

Answer 25

Medicare part D

Question 26

What type of health and drug insurance plan are designed for people of any age with low-income and insufficient resources, and that the federal and state government fund it with tax dollars?

Answer 26

Medicaid

Question 27

What type of conformation is known when a pharmacy notifies (by fax) the prescriber that the insurance company refused to pay a claim until they’ve received more details about the prescribed drug (expensive) and cheaper alternatives, taking an additional 2-3 days for the insurance company to process the conformation once the prescriber has taken action, and without any guarantee that the insurance company will pay the claim as well?

Answer 27

Prior authorization

Question 28

What type of insurance plan has a limit to the quantity of the medication they will cover, and that trying to bill the plan for more of the medication quantity or more of the days supply from the limitation of the original insurance plan will be rejected?

Answer 28

Plan limitation

Question 29

What type of manager is the administrator of the prescription drug portion of a health insurance plan, and they enter into pharmacies contracts, developing formularies, and processes prescription drug claims?

Answer 29

Pharmacy benefits manager (PBM)

Question 30

What type of program provides financial help for patients that cannot afford their medications?

Answer 30

Medication assistance program (MAP)

Question 31

What type of process prescription drug has its own fine print (terms and conditions) that may restrict use, has a similar insurance claim process that requires the same “BIN”, “PCN”, “group number”, and “ID number” numerics, which cannot be used by patients who are on a “Medicaid” or “Medicare part D” insurance programs, and used by patients when presenting it to the pharmacy after the drug filling is completed?

Answer 31

Drug coupon

Question 32

What type of coordination charges each party payer the full amount to the primary payer and only the remainder to the secondary payer, and so on, also billing two or more third party payers at the same time, and taking measures to ensure each payer pays the proper amount and not charging each payer for the full amount of the claim?

Answer 32

Coordination of benefits