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Module 9

Section 1:Types of third-party programs

QuestionAnswer
What are third-party programs? Private health benefit programs and government-run programs that pay for prescriptions on behalf of patients
Who are the three parties involved in third-party programs The patient who receives a service The provider (the pharmacist) The group that pays for all or part of the service (government program or private insurer)
What are the three basic types of third-party programs? Traditional indemnity Managed indemnity Managed care
Which type of third -party program allows a patient to choose any provider they like without a referral from their primary care provider? Traditional indemnity plan
Which type of third-party program allows a patient to see any provider they choose but may require approval from the insurer or primary care provider for certain services? Managed indemnity plan
Which type of programs use provider networks that include or exclude providers based on their compatibility with the plan's objectives? Managed care plans
What is the major difference between health maintenance organizations (HMO's) and preferred provider organizations (PP)'s)? HMOs generally restrict patients from using providers who are not part of their network, whereas PPos allow patients to see providers outside of their network. However, patients on a PPO plan pay a smaller percentage of eh cost when using an in-network provider.
What are Pharmacy benefit managers (PBMS) main administrative services related to pharmacy? Contract with pharmacies to provide specified services Reimburse pharmacies Audit pharmacies Process claims submitted by pharacies
To which groups of individuals does Medicare provide coverage? Adults age 65 and over Individuals who have disabilities
How is eligibility for Medicaid usually determined by states? Based on income
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