CEBS GBA 1 Practice Exam brand new version correct
Questions and verified answers graded a+
Prior authorization is generally used for what kind of drugs? -answer-High cost drugs
($250-$2,000)
What are some of the negative effects of combining pharmacy plan with medical? -
answer-- 25% more expensive
- Medical claims processors do not require detailed receipts so it it difficult to
understand effectiveness or trends
- rebates are not available
A program of managed care that reviews the drugs taken by the patient to validate
whether they are the best choices for an optimal outcome. -answer-Drug Utilization
Review (DUR)
This DUR takes place at the point of service (pharmacy) and will flag potential overuse
based on clinical monitoring criteria to prevent overuse/abuse.
› Hard Edits =
- For times where the refill is to soon
- When there are duplicate claims
- The drug needs prior authorization
- There are quantity limits
› Soft Edits =
- When there may be drug interactions between the prescription and ones the patient is
taking already -answer-Concurrent DURs
Uses pharmacists or nurses to review patient profiles to:
- Determine if a patient is complying with drug therapy or
- Suggest alternative therapies to the patient's physician that are more cost effective
› PBMs tend to resist because it could lead to a prescription not being filled and that's
how they make profits.
,› PBMs may turn to therapeutic switching as a type of retrospective DUR. The caveat to
this is switching merely substitutes one drug for another rather than determining
appropriateness of the drug. -answer-Retrospective DURs
› Educate physicians and patients about drugs/drug therapy
› PBMs have not had success with this type of program in general or in justifying the
ROI
› Often funded by drug manufacturers (their agenda may be profits for the
manufacturer) -answer-Prospective DURs
A list of drugs preferred by the health plan centered on brand names (even though
generics may be 'preferred').
- designed by a process of evaluation and analysis usually under the direction of a
pharmacy and therapeutics (P&T) committee. -answer-Formulary
P&T committees are comprised of: -answer-› physicians, pharmacists, and nurses
› May include pharmacoeconomists, ethicists, the general public, plan administration
- Are responsible for evaluating all available evidence to choose medications to treat
conditions applicable to the insured population
Academy of Managed Care Pharmacy has: -answer-- standardized P&T deliberations
- ensured all info is available for analysis
- ensures economic considerations are fully vetted and specific to the insured
population
Allow participants to have any covered prescription drug prescribed for them
-Gives the perception of freedom of choice
- Typically include hundreds of medications and several options per drug category
- Physicians are typically only familiar with a few select medications, thus they prefer
open formularies
- Patients and physicians can make better informed decisions with open formularies—
both have list of inclusions.
- More prevalent in self-funded plans -answer-Open formularies
Has designated medications that, when chosen, result in a reduced copayment
Most physicians and patients can find effective medication options in a preferred
formulary
More prevalent in self-funded plans
Drugs not listed may still be covered with a higher cost to the patient -answer-
Preferred formularies
Has an identified set of medications to choose from
Does not allow for non-listed medications (non-formulary) to be used
Physicians and patients are resistant due to lack of choice
Typically found in hospital settings and tightly managed HMOs
,Not a top design choice for most employers -answer-Closed formularies
What are some of the advantages of formularies? -answer-Cost reduction - they can
save about 15 % in drug costs
Encourage patients to use the most cost-effective medications in a class
Help educate patients and physicians about cost effective alternatives
They are a ready source of pharmacy medications the plan sponsor can defer to, but
plan sponsors must ensure to meet the specifications of the plan's benefit
What are some of the disadvantages of formularies? -answer-Time consuming to
communicate list of preferred products to patients and physicians
There may be different formularies within a health plan, making it challenging to
manage
When changes are made to the formulary and communication is not made, it can
negatively impact the patient based on medication availability or a copay change
Patients and physicians may be dissatisfied with the limitations on selection within a
particular drug class to obtain the lowest copayment option
What are the two types of disease state management programs? -answer-- The
medical model
• Call centers staffed by nurses and assistants to triage patients to appropriate levels of
cares
• Follow-up on patients with select diseases to ensure they are scheduling doctor
appointments, receiving appropriate tests and procedures, and understanding the
importance of taking their medications
- The therapy-directed model
• Directed by PBMs, pharmaceutical manufacturers, health plans, and disease
management companies
• Foster improved compliance with:
› Medication therapy
› Patient education
› Testing for outcomes of care
Allows doctors to dispense certain drugs from their offices
• Generally associated with worker's compensation programs
• Dispensing the most frequently prescribed medications that can be easily stocked
• Generally, medications for acute rather than chronic conditions -answer-Point of
dispensing
How do PBMs to generate profits? -answer-• Administrative fee per transaction
• Retaining rebate administrative fees
• Filling mail service prescriptions from the PBM's own mail pharmacy
• Providing services such as disease management, education, etc.
• Discounts via a contracted network of pharmacies
• Retaining the pharmacy spread
, • The pharmacy collects the full copay amount, even when the cost of the drug is less
than the copay
• This allows PBMs to extract greater discounts from pharmacies for clients
• The plan does not lose, but the patient does -answer-Zero-balance billing
An agreement between a PBM and a drug manufacturer to secure significant reductions
in the cost of prescription drugs. Many PBMs do not disclose this to plan sponsors. -
answer-Rebates
The price of a drug assigned by the drug manufacturer and used as a reference price
for all discounts paid to pharmacies and pharmacy benefit managers -answer-Average
wholesale price (AWP)
The price of a drug at which wholesalers buy pharmaceuticals from manufacturers -
answer-Wholesale acquisition cost (WAC)
Set by the Medicaid program, this is the upper price limit for all generic medications -
answer-Maximum allowable cost (MAC)
A special classification of medications not covered by a plan -answer-Exclusions
Drugs made from living cells that treat various diseases. -answer-Biotechnology
medications
A type of drug utilization program for educating physicians about drugs or drug
therapies -answer-Prospective review
A predefined maximum quantity for specific medications that restricts the number of
dosage units. It may be used to prevent abuse or overuse of the medication. -answer-
Quantity limits
A drug utilization program that requires the pharmacist or nurse to review the patient
profile to determine if they are complying with drug therapy or to suggest alternative
therapies. -answer-Retrospective Review
A program that measures/manages all healthcare outcomes and costs associated with
a particular disease across the entire continuum of healthcare delivery. -answer-
Disease state management program
A type of disease state management program that uses call centers staffed by nurses to
triage patients with select diseases to appropriate levels of care and to follow up with
them -answer-Medical model
Questions and verified answers graded a+
Prior authorization is generally used for what kind of drugs? -answer-High cost drugs
($250-$2,000)
What are some of the negative effects of combining pharmacy plan with medical? -
answer-- 25% more expensive
- Medical claims processors do not require detailed receipts so it it difficult to
understand effectiveness or trends
- rebates are not available
A program of managed care that reviews the drugs taken by the patient to validate
whether they are the best choices for an optimal outcome. -answer-Drug Utilization
Review (DUR)
This DUR takes place at the point of service (pharmacy) and will flag potential overuse
based on clinical monitoring criteria to prevent overuse/abuse.
› Hard Edits =
- For times where the refill is to soon
- When there are duplicate claims
- The drug needs prior authorization
- There are quantity limits
› Soft Edits =
- When there may be drug interactions between the prescription and ones the patient is
taking already -answer-Concurrent DURs
Uses pharmacists or nurses to review patient profiles to:
- Determine if a patient is complying with drug therapy or
- Suggest alternative therapies to the patient's physician that are more cost effective
› PBMs tend to resist because it could lead to a prescription not being filled and that's
how they make profits.
,› PBMs may turn to therapeutic switching as a type of retrospective DUR. The caveat to
this is switching merely substitutes one drug for another rather than determining
appropriateness of the drug. -answer-Retrospective DURs
› Educate physicians and patients about drugs/drug therapy
› PBMs have not had success with this type of program in general or in justifying the
ROI
› Often funded by drug manufacturers (their agenda may be profits for the
manufacturer) -answer-Prospective DURs
A list of drugs preferred by the health plan centered on brand names (even though
generics may be 'preferred').
- designed by a process of evaluation and analysis usually under the direction of a
pharmacy and therapeutics (P&T) committee. -answer-Formulary
P&T committees are comprised of: -answer-› physicians, pharmacists, and nurses
› May include pharmacoeconomists, ethicists, the general public, plan administration
- Are responsible for evaluating all available evidence to choose medications to treat
conditions applicable to the insured population
Academy of Managed Care Pharmacy has: -answer-- standardized P&T deliberations
- ensured all info is available for analysis
- ensures economic considerations are fully vetted and specific to the insured
population
Allow participants to have any covered prescription drug prescribed for them
-Gives the perception of freedom of choice
- Typically include hundreds of medications and several options per drug category
- Physicians are typically only familiar with a few select medications, thus they prefer
open formularies
- Patients and physicians can make better informed decisions with open formularies—
both have list of inclusions.
- More prevalent in self-funded plans -answer-Open formularies
Has designated medications that, when chosen, result in a reduced copayment
Most physicians and patients can find effective medication options in a preferred
formulary
More prevalent in self-funded plans
Drugs not listed may still be covered with a higher cost to the patient -answer-
Preferred formularies
Has an identified set of medications to choose from
Does not allow for non-listed medications (non-formulary) to be used
Physicians and patients are resistant due to lack of choice
Typically found in hospital settings and tightly managed HMOs
,Not a top design choice for most employers -answer-Closed formularies
What are some of the advantages of formularies? -answer-Cost reduction - they can
save about 15 % in drug costs
Encourage patients to use the most cost-effective medications in a class
Help educate patients and physicians about cost effective alternatives
They are a ready source of pharmacy medications the plan sponsor can defer to, but
plan sponsors must ensure to meet the specifications of the plan's benefit
What are some of the disadvantages of formularies? -answer-Time consuming to
communicate list of preferred products to patients and physicians
There may be different formularies within a health plan, making it challenging to
manage
When changes are made to the formulary and communication is not made, it can
negatively impact the patient based on medication availability or a copay change
Patients and physicians may be dissatisfied with the limitations on selection within a
particular drug class to obtain the lowest copayment option
What are the two types of disease state management programs? -answer-- The
medical model
• Call centers staffed by nurses and assistants to triage patients to appropriate levels of
cares
• Follow-up on patients with select diseases to ensure they are scheduling doctor
appointments, receiving appropriate tests and procedures, and understanding the
importance of taking their medications
- The therapy-directed model
• Directed by PBMs, pharmaceutical manufacturers, health plans, and disease
management companies
• Foster improved compliance with:
› Medication therapy
› Patient education
› Testing for outcomes of care
Allows doctors to dispense certain drugs from their offices
• Generally associated with worker's compensation programs
• Dispensing the most frequently prescribed medications that can be easily stocked
• Generally, medications for acute rather than chronic conditions -answer-Point of
dispensing
How do PBMs to generate profits? -answer-• Administrative fee per transaction
• Retaining rebate administrative fees
• Filling mail service prescriptions from the PBM's own mail pharmacy
• Providing services such as disease management, education, etc.
• Discounts via a contracted network of pharmacies
• Retaining the pharmacy spread
, • The pharmacy collects the full copay amount, even when the cost of the drug is less
than the copay
• This allows PBMs to extract greater discounts from pharmacies for clients
• The plan does not lose, but the patient does -answer-Zero-balance billing
An agreement between a PBM and a drug manufacturer to secure significant reductions
in the cost of prescription drugs. Many PBMs do not disclose this to plan sponsors. -
answer-Rebates
The price of a drug assigned by the drug manufacturer and used as a reference price
for all discounts paid to pharmacies and pharmacy benefit managers -answer-Average
wholesale price (AWP)
The price of a drug at which wholesalers buy pharmaceuticals from manufacturers -
answer-Wholesale acquisition cost (WAC)
Set by the Medicaid program, this is the upper price limit for all generic medications -
answer-Maximum allowable cost (MAC)
A special classification of medications not covered by a plan -answer-Exclusions
Drugs made from living cells that treat various diseases. -answer-Biotechnology
medications
A type of drug utilization program for educating physicians about drugs or drug
therapies -answer-Prospective review
A predefined maximum quantity for specific medications that restricts the number of
dosage units. It may be used to prevent abuse or overuse of the medication. -answer-
Quantity limits
A drug utilization program that requires the pharmacist or nurse to review the patient
profile to determine if they are complying with drug therapy or to suggest alternative
therapies. -answer-Retrospective Review
A program that measures/manages all healthcare outcomes and costs associated with
a particular disease across the entire continuum of healthcare delivery. -answer-
Disease state management program
A type of disease state management program that uses call centers staffed by nurses to
triage patients with select diseases to appropriate levels of care and to follow up with
them -answer-Medical model
