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Module 9

Section 2: Prescription reimbursement

QuestionAnswer
Which two pieces of information can help a pharmacy technician answer patient questions about their out-of-pocket costs? How a medication is priced How a patient's cost sharing is determined
Upon which two factors is reimbursement to pharmacies based? Drug ingredient cost Dispensing fee
What is the price the pharmacy department pays for the medication? Drug ingredient cost
What is the cost to cover the pharmacy department staff labor and overhead expenses to fill the prescription? Dispensing fee
Which form of patient cost sharing requires patients to pay a specified dollar amount for every prescription received? Copayments
Which form of cost sharing requires patients to pay a specified percentage of heir prescription expenses? Coinsurance
A plan only covers prescription expenses after the patient has paid a specified dollar amount out of pocket. Which form of cost sharing does this describe? Deductibles
The amount of cost sharing varies on the basis of which two factors? The particular medication that the provider has prescribed The plan's benefit design
The total reimbursement for a medication is $50 and the patient is responsible to pay 20% coinsurance. What amount is paid by the pharmacy's pharmacy benefit manager (PBM)? The patient is responsible for $50 x 0.20 = $10. Therefore, the PBM pays $50 - $10 = $40.
The total reimbursement for a medication is $110. The patient has a $300 deductible but has not paid for any prescriptions this year. What is the patient's responsibility for this medication? The pharmacy benefit manager will not provide any reimbursement before the deductible is met, so the patient's responsibility is the full $110.
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