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Chapter 15: Pharm
Chapter 15: Financial Issues
| Question | Answer |
|---|---|
| What was the reason for the increase of retail prescription drugs expenditures from 12 billion to 271.1 billion? | Inflation, population growing up, and new medications that improve the quality of health care but are costly. |
| What are third-party programs? | Another party besides the patient or the pharmacy that pays for some or all of the cost of medication, like insurance companies. |
| What are pharmacy benefit managers (PBM)? | Companies that administer drug benefit programs bcs not all insurers pay for meds. Negotiate on behalf of pharmacy and insurer to control drug spending. |
| What are the 3 largest/well known PBMs? | Express Scripts, CVS/Caremark, OptumRx |
| What is online adjudication? | The resolution of prescription coverage through the communication of the pharmacy computer with the third-party computer. Most claims are processed through here. |
| What is co-insurance? | An agreement between the insurer and the insured to share costs. The expense would be a percentage. |
| What is co-pay? | The portion of the medication's price that the patient is required to pay and the insurance company is billed for the remainder. |
| What is maximum allowable cost (MAC)? | The maximum price per tablet ( or other dispensing unit) an insurer or PBM will pay for a given product. |
| What is usual and customary or usual, customary, and reasonable (U&C or UCR)? | The maximum amount of payment for a given prescription , determined by the insurer to be a usual and customary (and reasonable) price for prescription in an specific geographic area. |
| What is dual co-pay? | Co-pays that have two prices: one for generic and one for brand medications. The lower co-pay applies to prescriptions filled with generic drugs and a higher co-pay applies to prescriptions filled with brand name drugs (that don't have generics). |
| Some plans have three different co-pays, what are they? | The lowest co-pay applies to prescriptions that are tier one drugs (generics); the higher co-pay is tier two brand name drugs; and the third higher applies to tier three brand name drugs. |
| What is a deductible ? | A set amount that must be paid by the patient for each benefit period before the insurer will cover additional expenses. |
| What is a formulary? | A list of medications covered by third-party plans. Probably going to be closed formularies (more cheaper). |
| What are prescription drug benefit cards? | Cards that contain third-party billing information for prescription drug purchases. |
| What does tier mean? | Categories of medications that are covered by third-party plans. |
| What are HMOs? (health maintenance organizations) | Providers (doctors, pharmacies) are employees of HMO or in contract to follow their policies (and pricing). Assigned PCP. Need referrals. Usually do not cover expenses outside network and require generic substitutes. |
| What are POS? (point-of-service organizations) | The patient's primary care physician must be a member; and costs outside the network may be partially reimbursed. The PCP must make referrals in order for the patient to receive outside POS network care. |
| What are PPOs? (preferred provider organizations) | Costs outside the network may be partially reimbursed and the patient's primary care physician does not need to be a member. Most flexibility for patients (more expensive organization). |
| What kind of information is included on a prescription drug benefit card? | Contain necessary billing information for pharmacies, including the patient's identification number, group number, and co-pay amount. |
| When does a coordination of benefits need to happen? | Two adults who are spouses that have two different health insurance plans, which could result in their dependent children having coverage on two different plans. |
| What does coordination of benefits provide? | Provide maximum coverage for health-care expenses through both heath insurance plans and ensure that the benefit coverage for a claim does not exceed 100%. One insurance company can do one portion, the other company does the other portion. |
| What are the two largest public health insurance plans in the United States? | Medicare and Medicaid |
| What are the three health insurances for veterans? | VA, TRICARE, CHAMPVA |
| What is Medicare? | A federal program providing health care to people 65 and older, disabled people under 65, people with kidney failure, and ALS. |
| What does Medicare Part A cover? | Covers inpatient hospital expenses for patients who meet certain conditions, and may cover some hospice expenses. |
| What does Medicare Part B cover? | For additional monthly premium, it covers doctor's services and some other medical services not covered in Part A. |
| What is Medicare Prescription Drug Plan or Medicare Part D? | Participants must meet certain deductibles and co-payments. May have prescription drug coverage through current or former employer if not part of Plan D. Some benefits are qualifying for Medication Therapy Management (MTM) services. |
| What is Medicaid? | A federal-state program for eligible individuals and families with low incomes. |
| Who decides who is eligible and what is covered for Medicaid? | State welfare departments |
| Medicaid recipients can also qualify for what? | HMO programs |
| What is VA? | Provides health-care benefits for eligible veterans. Covers prescriptions written by VA doctors at VA pharmacies. Mail order option w/ Consolidated Mail Outpatient Pharmacy program (CMOP). |
| What was TRICARE formerly known as? | Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) |
| What is TRICARE? | Provides health-care benefits for eligible uniformed service members, retirees, and family members. Pharmacy benefits administered through PBM-prescription filled at network pharmacy, military pharmacy, or mail. |
| What is CHAMPVA? | Provides coverage for some spouses and children of disabled or deceased veterans who are not eligible for TRICARE. Prescription benefits administered through PBM. |
| What is worker's compensation? | An employer compensation program for employees accidentally injured on the job. Some provide coverage for occupational diseases. |
| What are patient assistance programs? | Offered by some pharmaceutical manufacturers to help needy patients who do not have insurance coverage and require medication they cannot afford. Application must be completed by physician and patient. |
| What is the online process? | Fill out the necessary information from the prescription drug card, billing information is then transmitted to insurer or PBM, carefully review the adjudication info before printing the receipt and label, hardcopies or online copies are kept. |
| What is dispensing code 0? | No DAW |
| What is dispensing code 1? | DAW written on the prescription by prescriber |
| What is dispensing code 2? | Patient requested brand |
| What is dispensing code 3? | Pharmacist selected brand |
| What is dispensing code 4? | Generic not in stock |
| What is dispensing code 5? | Brand name is dispensed at generic price. |
| What is dispensing code 6? | N/A or Override |
| What is dispensing code 7? | Substitution not allowed (brand is required by law) |
| What is dispensing code 8? | Generic not available (not made yet) |
| What is dispensing code 9? | Other |
| On an insurance card, what is a group number? | Identifies employer or other group insurance plan |
| What is card issuer ID? | A unique identifier for the health plan. |
| What is member ID? | A unique number, sometimes the same as the member's SS number. |
| What is RxBIN? | A number/code identifying where to send the claim. |
| What is RxPCN? | A number/code identifying which company processes claims. |
| What are person codes? | Identifying codes used when multiple persons are listed on the same card. |
| What is Rx Group? | A number/code identifying the specific benefits that apply to the plan. |
| What are some common reasons for third party claim rejections? | Dependent exceeded age limit, invalid birth date/person code/sex, refill too soon/not covered, NDC not covered, Prescriber is not network provider, unable to connect with insurer's computer, patient is not covered, invalid day's supply. |
| What is prior authorization? | A procedure to gain third-party coverage for a drug that is not automatically covered by a third-party plan. |
| What is an universal claim form (UCF)? | A standard claim form accepted by many insurers. |
| What are the conditions most often targeted for disease state management? | Diabetes, HTN, high BP, asthma, smoking cessation, and cholesterol management. |
| What is CMS-1500 form? | The standard form used by health-care providers to bill for services, including disease state management services. All sent to PBM. |
| What is Medication Therapy Management (MTM) services? | Services provided to some Medicare beneficiaries who are enrolled in Medicare Part D and who are taking multiple medications or have certain diseases. |
| What are Prescription Drug Plans (PDPs)? | Third-party programs for Medicare Part D |
| In order to bill prescription drug plans for MTM services using the CMS-1500 form, what does the pharmacy need to be enrolled as? | The pharmacist or pharmacy offering services must be enrolled as a provider for the patient's PDP and also have a NPI. |
| What is a National Identifier Provider (NPI)? | The code assigned to recognized health-care providers needed to bill MTM services. |
| What is the CMS-10114 form? | The standard six-page form used by health-care providers to apply for a national provider identifier (NPI). |
| What are the Current Procedural Terminology codes (CPT) codes? | Identifiers used for billing pharmacist-provided MTM services. |
| What are the three different CPT codes that can be used to bill prescription drugs & for MTM? | 99605, 99606, 99607 |
| What is code 99605? | Used for first encounter with a patient and may be billed in 1-5 minute increments. |
| What is code 99606? | Used for follow up encounters and may be billed in 1-5 min increments. |
| What is code 99607? | An add-on CPT code to be used 99605 or 99606 when additional 15 min increments of time are spent face to face with a patient. |
| Before a prescription can be filled what needs to happen? | Pharmacy needs to sign a contract with insurers or PBM. |
| What needs to happen before deductible is met? | Some insurance companies offer drug coverage under policy but may have to pay out of pocket until the deductible is met. |
| What does a physician need to do if their patient needed a brand name drug that is not on the insurance's formulary? | Prior authorization form in order to get permission |
| What is required for dispensed medications when a prescription is billed online? | Insurers and PBM's require a signature log (hardcopy or electronic) |
| If a brand name is dispensed, what codes needs to be present? | One of the following DAW codes is entered in the dispensing code field. |
| What is the universal claim form (UCF)? | It is a paper claim and not used often, and you fill in the same information for online adjudication. The patient would need to pay up front if they need the prescription right away and be reimbursed later. |
| What is in-house billing ? | A responsible party is billed for patient's co-pay. |
| What are disease management services? | Special service provided by PBM's to employers and health insurance companies. |
| What did the Medicare Modernization act do? | Put into effect with medication therapy management with pharmacists and brought in Medicare Part D. |
Created by:
imaliha2003
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