Understanding managed care systems is essential for pharmacists to effectively navigate formulary restrictions, improve medication access, and contribute to cost-effective healthcare delivery. Managed care emphasizes prevention, quality outcomes, and collaboration across healthcare providers to manage patient populations. This MCQ quiz helps Pharm.D. students grasp key components such as pharmacy benefit management, utilization review, formulary design, prior authorizations, and quality measures within managed care environments.
1. What is the main goal of managed care?
- A. Increase medication costs
- B. Maximize provider autonomy
- C. Deliver cost-effective, quality care to a defined population
- D. Eliminate insurance systems
Correct answer: C. Deliver cost-effective, quality care to a defined population
2. A Pharmacy Benefit Manager (PBM) is responsible for:
- A. Licensing physicians
- B. Managing prescription drug benefits on behalf of insurers
- C. Developing hospital budgets
- D. Selling over-the-counter supplements
Correct answer: B. Managing prescription drug benefits on behalf of insurers
3. Which of the following is an example of utilization management?
- A. Co-payment collection
- B. Patient marketing
- C. Prior authorization requirements
- D. Direct-to-consumer advertising
Correct answer: C. Prior authorization requirements
4. The purpose of a drug formulary in managed care is to:
- A. Limit pharmacist roles
- B. Increase medication sales
- C. Provide a list of approved medications for coverage
- D. List side effects of drugs
Correct answer: C. Provide a list of approved medications for coverage
5. Step therapy is a managed care policy that:
- A. Requires trying lower-cost drugs before others
- B. Eliminates physician review
- C. Automatically fills all prescriptions
- D. Bypasses clinical guidelines
Correct answer: A. Requires trying lower-cost drugs before others
6. A formulary tier system typically categorizes medications based on:
- A. Color codes
- B. Side effects
- C. Cost-sharing levels
- D. Alphabetical order
Correct answer: C. Cost-sharing levels
7. What is the role of DUR (Drug Utilization Review) in managed care?
- A. Approving insurance payments
- B. Monitoring prescribing and medication use for safety and effectiveness
- C. Managing employee benefits
- D. Marketing generic drugs
Correct answer: B. Monitoring prescribing and medication use for safety and effectiveness
8. A key component of managed care pharmacy is:
- A. Dispensing without restrictions
- B. Direct cash payments only
- C. Medication therapy management (MTM)
- D. Avoiding patient counseling
Correct answer: C. Medication therapy management (MTM)
9. Capitation is a payment model where:
- A. Providers are paid for each service performed
- B. Providers receive a fixed amount per patient regardless of services used
- C. Patients pay full price
- D. Pharmacies charge based on inventory
Correct answer: B. Providers receive a fixed amount per patient regardless of services used
10. A “preferred drug list” is used to:
- A. Increase co-pays
- B. Promote safe and cost-effective prescribing
- C. Limit physician access to drugs
- D. Require patient approval
Correct answer: B. Promote safe and cost-effective prescribing
11. PBMs use rebates to:
- A. Increase patient copays
- B. Encourage brand-name drug use
- C. Negotiate lower prices with manufacturers
- D. Bypass safety regulations
Correct answer: C. Negotiate lower prices with manufacturers
12. Which term describes a health plan that requires patients to see in-network providers?
- A. HMO (Health Maintenance Organization)
- B. PPO (Preferred Provider Organization)
- C. Medicare
- D. Fee-for-service
Correct answer: A. HMO (Health Maintenance Organization)
13. Prior authorization is used to:
- A. Avoid documentation
- B. Confirm medical necessity before medication approval
- C. Automatically fill prescriptions
- D. Increase pharmacy workload
Correct answer: B. Confirm medical necessity before medication approval
14. Quality assurance in managed care aims to:
- A. Evaluate cost of supplies
- B. Track medication sales
- C. Monitor and improve patient outcomes
- D. Manage advertising
Correct answer: C. Monitor and improve patient outcomes
15. An example of a value-based care initiative is:
- A. Paying for number of prescriptions filled
- B. Incentivizing providers for quality outcomes and reduced hospitalizations
- C. Reducing pharmacy hours
- D. Increasing copays
Correct answer: B. Incentivizing providers for quality outcomes and reduced hospitalizations
16. What is a downside of managed care restrictions like step therapy?
- A. Encourages new drug use
- B. May delay access to effective medications
- C. Eliminates the need for counseling
- D. Reduces paperwork
Correct answer: B. May delay access to effective medications
17. The acronym “MTM” stands for:
- A. Medication Transfer Monitoring
- B. Medication Therapy Management
- C. Multi-Tiered Medication
- D. Managed Therapeutic Mandate
Correct answer: B. Medication Therapy Management
18. In managed care, “case management” refers to:
- A. Lawsuit tracking
- B. Coordination of services for high-risk patients
- C. Monitoring generic inventory
- D. Medical coding review
Correct answer: B. Coordination of services for high-risk patients
19. Which organization often accredits managed care organizations for quality?
- A. CDC
- B. DEA
- C. NCQA (National Committee for Quality Assurance)
- D. FDA
Correct answer: C. NCQA (National Committee for Quality Assurance)
20. A patient’s out-of-pocket cost is usually lowest when:
- A. Using non-formulary drugs
- B. Choosing brand-name drugs
- C. Selecting generic drugs from the preferred list
- D. Skipping insurance
Correct answer: C. Selecting generic drugs from the preferred list
21. Which plan type offers more provider flexibility but higher costs?
- A. HMO
- B. Medicare Part B
- C. PPO
- D. Medicaid
Correct answer: C. PPO
22. Which healthcare professional is most involved in formulary development?
- A. Pharmacists
- B. Dentists
- C. Lab technicians
- D. Physical therapists
Correct answer: A. Pharmacists
23. “Star Ratings” in Medicare Part D are used to:
- A. Rank PBMs
- B. Grade pharmacies’ adherence to drug laws
- C. Evaluate plan quality based on measures like medication adherence
- D. Compare hospital room sizes
Correct answer: C. Evaluate plan quality based on measures like medication adherence
24. The term “benefit design” in managed care refers to:
- A. Store layout
- B. Rules and structure of a health insurance plan
- C. Pill appearance
- D. Patient satisfaction reviews
Correct answer: B. Rules and structure of a health insurance plan
25. What is the primary role of formulary committees?
- A. Track sales data
- B. Approve all generic drugs
- C. Evaluate medications based on evidence and cost-effectiveness
- D. Market new therapies
Correct answer: C. Evaluate medications based on evidence and cost-effectiveness
26. In managed care, “cost containment” refers to:
- A. Preventing drug recalls
- B. Minimizing out-of-pocket costs and resource waste
- C. Increasing brand-name use
- D. Avoiding preventive care
Correct answer: B. Minimizing out-of-pocket costs and resource waste
27. A patient’s “formulary exclusion” means:
- A. The drug is free
- B. The drug is fully covered
- C. The drug is not covered under their plan
- D. The pharmacist must explain it
Correct answer: C. The drug is not covered under their plan
28. What best describes “risk-sharing contracts” between payers and manufacturers?
- A. Patients split copays
- B. Manufacturers get bonuses
- C. Manufacturers are reimbursed based on drug effectiveness
- D. Pharmacies receive loyalty rewards
Correct answer: C. Manufacturers are reimbursed based on drug effectiveness
29. The role of a P&T (Pharmacy and Therapeutics) committee includes:
- A. Developing software
- B. Marketing drugs
- C. Making formulary decisions based on clinical and economic data
- D. Auditing physicians
Correct answer: C. Making formulary decisions based on clinical and economic data
30. Rebate contracts are often used by PBMs to:
- A. Fund new medications
- B. Drive brand preference on formularies
- C. Pay pharmacists bonuses
- D. Avoid reporting requirements
Correct answer: B. Drive brand preference on formularies
31. Adherence metrics are crucial in managed care because:
- A. They predict billing success
- B. They influence TV ads
- C. They are linked to patient outcomes and cost control
- D. They are collected by manufacturers only
Correct answer: C. They are linked to patient outcomes and cost control
32. In managed care, an “open formulary” means:
- A. Few restrictions on medication access
- B. Only generic drugs are allowed
- C. No prior authorizations
- D. Unlimited prescribing power
Correct answer: A. Few restrictions on medication access
33. An “exclusive formulary” implies:
- A. High out-of-pocket costs
- B. Only one drug per therapeutic category is covered
- C. No generic drugs allowed
- D. Patients choose coverage
Correct answer: B. Only one drug per therapeutic category is covered
34. Disease management programs in managed care focus on:
- A. Advertising health plans
- B. Preventing brand-name prescribing
- C. Improving outcomes for chronic conditions
- D. Reducing pharmacist roles
Correct answer: C. Improving outcomes for chronic conditions
35. Formulary changes are usually made:
- A. Once every decade
- B. Randomly
- C. Periodically by P&T committees
- D. Based on store inventory
Correct answer: C. Periodically by P&T committees
36. Generic substitution policies are encouraged in managed care because they:
- A. Increase side effects
- B. Promote brand-name loyalty
- C. Reduce medication costs
- D. Confuse patients
Correct answer: C. Reduce medication costs
37. MTM services in Medicare Part D are required for:
- A. All enrollees
- B. Enrollees with multiple chronic conditions and high drug costs
- C. Pediatric patients
- D. Hospitalized patients only
Correct answer: B. Enrollees with multiple chronic conditions and high drug costs
38. Cost-sharing in managed care typically includes:
- A. Inventory fees
- B. Copayments, coinsurance, and deductibles
- C. Pharmacist bonuses
- D. Manufacturer rebates
Correct answer: B. Copayments, coinsurance, and deductibles
39. “Formulary management” helps improve:
- A. TV ratings
- B. Regulatory burden
- C. Appropriate medication use and cost efficiency
- D. Free sample distribution
Correct answer: C. Appropriate medication use and cost efficiency
40. What is the significance of STAR adherence measures?
- A. Evaluating employee attendance
- B. Medicare’s metric for plan quality based on adherence
- C. Pharmacy’s ability to stock medication
- D. Legal compliance
Correct answer: B. Medicare’s metric for plan quality based on adherence
41. What does “network pharmacy” mean?
- A. Any pharmacy in the U.S.
- B. A pharmacy under contract with an insurance plan
- C. A state-run pharmacy
- D. An academic institution
Correct answer: B. A pharmacy under contract with an insurance plan
42. What’s the purpose of “real-time benefit checks”?
- A. Inventory control
- B. Immediate information on coverage and cost during prescribing
- C. Scheduling refills
- D. Calculating pharmacist bonuses
Correct answer: B. Immediate information on coverage and cost during prescribing
43. Integrated delivery systems (IDS) aim to:
- A. Maximize vendor competition
- B. Fragment care
- C. Coordinate care across services and providers
- D. Promote retail chains
Correct answer: C. Coordinate care across services and providers
44. Which of these improves medication access in managed care?
- A. Brand-only coverage
- B. Mail-order pharmacy
- C. Step therapy without appeals
- D. Paper claims
Correct answer: B. Mail-order pharmacy
45. Which outcome reflects successful managed care implementation?
- A. Increased ER visits
- B. Fragmented records
- C. Improved health outcomes at lower cost
- D. Brand preference for all patients
Correct answer: C. Improved health outcomes at lower cost
46. What is the role of “utilization review” in managed care?
- A. Set drug prices
- B. Audit billing
- C. Evaluate appropriateness, efficiency, and medical necessity
- D. Manage patient complaints
Correct answer: C. Evaluate appropriateness, efficiency, and medical necessity
47. Who benefits most from MTM services?
- A. Healthy adults
- B. Patients with complex medication regimens and chronic conditions
- C. Pediatric patients
- D. Over-the-counter buyers
Correct answer: B. Patients with complex medication regimens and chronic conditions
48. Which type of managed care plan allows out-of-network coverage?
- A. HMO
- B. PPO
- C. FSA
- D. HSA
Correct answer: B. PPO
49. A key focus of value-based care in managed systems is:
- A. Increasing services provided
- B. Paying for improved outcomes
- C. Reducing prescriptions
- D. Banning brand names
Correct answer: B. Paying for improved outcomes
50. What is a major pharmacist responsibility in managed care settings?
- A. Marketing insurance plans
- B. Processing invoices
- C. Promoting rational drug use and managing formularies
- D. Lobbying against PBMs
Correct answer: C. Promoting rational drug use and managing formularies