HCMG EXAM QUESTIONS AND ANSWERS LATEST
EDITION ALREADY GRADED A+
formulary specialty tier
highest copayment or coinsurance; unique, very high cost drugs
how health insurers have moderated price increases
shift more cost to patients
patients with high deductible health plans
face higher share of costs
prior authorization (PA)
insurer must authorize coverage of the drug before the patient fills the prescription
step therapy
requires that patient starts on a less expensive drug; shift to more expensive one if first drug doesn't
work
quantity limits (QL)
limits the number of prescriptions/pill/refills that will be covered by the plan
generic substitution laws (state policy)
requirement of pharmacists to automatically substitute a brand with a generic when available; other
states allow pharmacists to do this
why prescriptions go unfilled
patient abandonment and payer rejection
pharmacy benefit managers benefits (PBMs)
formulary and benefit design, negotiate with pharma companies for rebates and discounts, offer mail-
order pharmacy, disease management programs
how PBMs increase bargaining power
pooling together multiple insurers' patient populations
how PBMs reduce drug prices
use formularies
pharma companies offer rebates to PBMs
EDITION ALREADY GRADED A+
formulary specialty tier
highest copayment or coinsurance; unique, very high cost drugs
how health insurers have moderated price increases
shift more cost to patients
patients with high deductible health plans
face higher share of costs
prior authorization (PA)
insurer must authorize coverage of the drug before the patient fills the prescription
step therapy
requires that patient starts on a less expensive drug; shift to more expensive one if first drug doesn't
work
quantity limits (QL)
limits the number of prescriptions/pill/refills that will be covered by the plan
generic substitution laws (state policy)
requirement of pharmacists to automatically substitute a brand with a generic when available; other
states allow pharmacists to do this
why prescriptions go unfilled
patient abandonment and payer rejection
pharmacy benefit managers benefits (PBMs)
formulary and benefit design, negotiate with pharma companies for rebates and discounts, offer mail-
order pharmacy, disease management programs
how PBMs increase bargaining power
pooling together multiple insurers' patient populations
how PBMs reduce drug prices
use formularies
pharma companies offer rebates to PBMs
