test 5 Flashcards
what refers to both private health benefit programs and government-run programs that pay for prescriptions on behalf of patients?
third party programs
what are the three parties involved in third party programs
The Patient, The pharmacy ,and Insurer
What is the major difference between Health Maintenance Organizations (HMO’s) and Preferred Provider Organizations (PPO’s)?
HMO’s: Generally restrict patients from using providers not in their networkPPO’s: Allow patients to see providers out side of their network
What are Pharmacy Benefit Manager (PBM’s) main administrative services related to pharmacy
Contract pharmacies to provide specified services
Reimburse pharmacies
Audit pharmacies
Process claims submitted by pharmacies
Which groups of individuals do Medicare provide coverage?
Individuals with disabilities
People age 65+
What is a form of patient cost sharing that requires patients to pay a specified percentage of their prescription expences
Coinsuence
What is a form of patient cost sharing that requires patients to pay a specified dollar amount for every prescription receved
Copayment
What is a plan that only covers prescription expenses after the patient has paid a specified dollar amount out of pocket
Deductible
The total reimbursement for a medication is 50$ and the patient is respocable to pay 20% coinsurence what amount is payed by the PBM.
40$
What are all of the patient details on a typical insurance card
BIN Bank Identification Number
PCN Processer Control Number
Group number
Expiration Date
Patient Name
Person Code
dependents
ID Number
Date of birth
Insurance Name
Copayment Amount
Why do Pharmacy benefit Managers create lists of medications that are covered or excluded form coverage?
To control prescription cost
Why is it important for a Pharmacy Technician to follow procedures relating to partial fills?
To avoid charging the Pharmacy benefit manager (PBM) twice
What happens if a medication is not picked up by the patient within a specified period?
Medication is put back on the shelf, and third party or patient’s charge is reversed through claims reversal.
What is a 6 digit number that the pharmacy uses to identify which insurance provider should receive the claim
BIN#: Bank Identification number
What is an additional identifier that can be used to route prescription claims
PCN#: Processor control number
What identifies the specific benefits plan for the member.
Group Number
Using the wrong what can result in incorrect reimbursement rates or cause audit problems later
NDC Number
What is a list of medications that are covered
Positive formulary
What is a list of medications that are not covered
Negative formulary
What is a company that buys products from manufacturers and other manufactures and sells these to pharmacies
Wholesalers
Most pharmacies have a primary wholesaler, known as a what, that they take daily orders from
Primary vendor
What is created to ensure that a group of pharmacies gets the best prices by allowing them to purchase their products in bulk
A GPO group purchasing organization
What identifies the minimum number of units on hand that triggers a replenish order
A reorder point
What is the number of units that must be ordered to replenish the inventory to optimum level with out going over. Based on usage and the amount of time it takes to receive the order.
the reorder quantity
