Understanding prescription insurance is essential for pharmacists to assist patients in accessing medications affordably. This topic encompasses types of insurance, formularies, co-pays, prior authorizations, and claim adjudication. This quiz aligns with Pharm.D. courses like CIPPE and PHA5561 to help students grasp the practical and administrative aspects of pharmacy benefit management.
1. Prescription insurance primarily helps to:
- A. Increase drug prices
- B. Reduce patient out-of-pocket costs
- C. Eliminate doctor visits
- D. Delay medication access
Correct answer: B. Reduce patient out-of-pocket costs
2. A formulary is:
- A. A drug manufacturing guide
- B. A list of approved medications covered by an insurance plan
- C. A pharmacist’s reference book
- D. A legal document
Correct answer: B. A list of approved medications covered by an insurance plan
3. Co-pay refers to:
- A. A refund for unused medication
- B. The fixed amount a patient pays for a prescription
- C. The total drug cost
- D. Pharmacist wages
Correct answer: B. The fixed amount a patient pays for a prescription
4. Prior authorization is required when:
- A. A drug is over-the-counter
- B. A high-cost or non-formulary drug is prescribed
- C. A patient requests it
- D. Any prescription is filled
Correct answer: B. A high-cost or non-formulary drug is prescribed
5. Which of the following best describes claim adjudication?
- A. Filing a lawsuit
- B. Processing a prescription claim electronically with an insurer
- C. Making a cash transaction
- D. Reviewing a drug label
Correct answer: B. Processing a prescription claim electronically with an insurer
6. What does “Tier 1” in a formulary usually indicate?
- A. Brand-name drugs
- B. Non-covered drugs
- C. Preferred generic medications with lowest co-pay
- D. High-risk medications
Correct answer: C. Preferred generic medications with lowest co-pay
7. A deductible in insurance is:
- A. The amount the insurance pays for each prescription
- B. The total cost of insurance
- C. The amount a patient must pay before insurance starts covering costs
- D. A fine for non-compliance
Correct answer: C. The amount a patient must pay before insurance starts covering costs
8. A pharmacy benefit manager (PBM):
- A. Manages the physical layout of the pharmacy
- B. Controls prescription benefits on behalf of insurers
- C. Manufactures drugs
- D. Approves new drugs for the market
Correct answer: B. Controls prescription benefits on behalf of insurers
9. Which of these plans is a government-funded prescription program?
- A. PPO
- B. Medicare Part D
- C. HMO
- D. Bronze Plan
Correct answer: B. Medicare Part D
10. If a drug is “not covered,” a pharmacist may:
- A. Dispense it anyway
- B. File a prior authorization request or recommend an alternative
- C. Discard the prescription
- D. Bill the prescriber
Correct answer: B. File a prior authorization request or recommend an alternative
11. Dual eligibility in insurance means:
- A. Patient has no insurance
- B. Patient qualifies for both Medicare and Medicaid
- C. Two prescriptions per visit
- D. Two insurance companies always pay full price
Correct answer: B. Patient qualifies for both Medicare and Medicaid
12. Coordination of benefits refers to:
- A. Communication between doctor and pharmacist
- B. Process to determine which insurance pays first
- C. Distribution of drugs from manufacturer
- D. Timing medication intake
Correct answer: B. Process to determine which insurance pays first
13. An Explanation of Benefits (EOB) is:
- A. A detailed receipt from the pharmacy
- B. A document outlining insurance claim outcomes
- C. A physician referral
- D. A lab test report
Correct answer: B. A document outlining insurance claim outcomes
14. Which plan type generally allows patients to choose any provider but at a higher cost?
- A. HMO
- B. PPO
- C. Medicaid
- D. Medicare Part A
Correct answer: B. PPO
15. A reason a claim may be rejected at the pharmacy is:
- A. Drug expiration date
- B. Incorrect patient insurance ID
- C. Lack of refrigeration
- D. Absence of a pharmacist
Correct answer: B. Incorrect patient insurance ID
16. Insurance premiums are:
- A. One-time payments for drugs
- B. Monthly payments for insurance coverage
- C. Amount reimbursed to the pharmacy
- D. Pharmacy discount offers
Correct answer: B. Monthly payments for insurance coverage
17. A “step therapy” requirement means:
- A. The patient must take steps at home before medication
- B. Patients must try less expensive drugs before expensive ones
- C. Drugs are administered in steps
- D. Pharmacy must confirm walking ability
Correct answer: B. Patients must try less expensive drugs before expensive ones
18. The BIN number on an insurance card identifies:
- A. The patient’s billing address
- B. The pharmacy license number
- C. The insurance company’s processing system
- D. The number of prescriptions allowed
Correct answer: C. The insurance company’s processing system
19. The PCN on an insurance card is used to:
- A. Identify patient allergies
- B. Track prescription usage
- C. Route claim to appropriate processing center
- D. Authenticate the prescription
Correct answer: C. Route claim to appropriate processing center
20. If a patient’s insurance doesn’t cover a drug, the pharmacist should:
- A. Cancel the prescription
- B. Suggest over-the-counter alternatives
- C. Contact insurance or prescriber to explore options
- D. Demand cash payment only
Correct answer: C. Contact insurance or prescriber to explore options
21. Which of the following is typically NOT included in prescription insurance plans?
- A. Over-the-counter drugs
- B. Generic medications
- C. Brand-name drugs
- D. Formulary maintenance medications
Correct answer: A. Over-the-counter drugs
22. What is the role of the Group Number on an insurance card?
- A. It identifies the patient
- B. It links to a specific employer or plan group
- C. It’s used for patient birthdates
- D. It defines medication cost
Correct answer: B. It links to a specific employer or plan group
23. A grace period in prescription insurance refers to:
- A. Delay in starting treatment
- B. Extra days for payment before cancellation
- C. Trial period for new medications
- D. Pharmacy processing time
Correct answer: B. Extra days for payment before cancellation
24. What is a common reason for a prior authorization delay?
- A. Incomplete paperwork or lack of justification
- B. Busy pharmacy
- C. Slow computers
- D. Lack of patient contact
Correct answer: A. Incomplete paperwork or lack of justification
25. When a patient has both private and public insurance, which usually pays first?
- A. Medicaid
- B. Medicare
- C. Private insurance
- D. Veterans Affairs
Correct answer: C. Private insurance
26. “Out-of-network” means:
- A. Medication not in stock
- B. Provider or pharmacy not under patient’s plan
- C. Data connectivity issue
- D. Multiple claims submitted
Correct answer: B. Provider or pharmacy not under patient’s plan
27. A “formulary exception” is:
- A. A banned medication
- B. Permission to cover a non-formulary drug
- C. A discount program
- D. Over-the-counter offer
Correct answer: B. Permission to cover a non-formulary drug
28. Copay cards are provided by:
- A. Pharmacists
- B. Government agencies
- C. Drug manufacturers to help with brand-name medication costs
- D. Insurance billing companies
Correct answer: C. Drug manufacturers to help with brand-name medication costs
29. Medicare Part D covers:
- A. Hospital stays
- B. Durable medical equipment
- C. Prescription drugs
- D. Routine dental care
Correct answer: C. Prescription drugs
30. A patient’s coverage “lapse” means:
- A. Temporary change in dosage
- B. Interruption in insurance coverage
- C. Pharmacy shut down
- D. Return to previous therapy
Correct answer: B. Interruption in insurance coverage
31. Formularies are maintained and updated by:
- A. Pharmacists alone
- B. Government regulators
- C. Pharmacy and therapeutics (P&T) committees
- D. Wholesalers
Correct answer: C. Pharmacy and therapeutics (P&T) committees
32. Coinsurance is defined as:
- A. A fixed fee per medication
- B. A percentage of the medication cost shared by the patient
- C. A monthly membership fee
- D. Cost of drug delivery
Correct answer: B. A percentage of the medication cost shared by the patient
33. What is an insurance “claim”?
- A. A payment made to pharmacy by patient
- B. A request for reimbursement submitted to insurer
- C. A returned prescription
- D. A legal complaint
Correct answer: B. A request for reimbursement submitted to insurer
34. Drug discount programs are often used:
- A. By wholesalers
- B. To replace prescription insurance
- C. To provide cost savings for patients without insurance
- D. To reduce prescriber workload
Correct answer: C. To provide cost savings for patients without insurance
35. An “adjudicated” claim means:
- A. Denied for fraud
- B. Returned to prescriber
- C. Successfully processed by the insurer
- D. Hand-delivered
Correct answer: C. Successfully processed by the insurer
36. Which part of the Medicare program covers physician services?
- A. Part A
- B. Part B
- C. Part C
- D. Part D
Correct answer: B. Part B
37. Medicaid is designed to provide coverage for:
- A. Military families
- B. Low-income individuals and families
- C. Business owners
- D. Foreign travelers
Correct answer: B. Low-income individuals and families
38. “Tier 4” medications on a formulary typically involve:
- A. OTCs
- B. Preferred brands
- C. Specialty or high-cost drugs
- D. Vaccines only
Correct answer: C. Specialty or high-cost drugs
39. A pharmacy technician’s role in insurance includes:
- A. Diagnosing patients
- B. Approving medical procedures
- C. Entering insurance information and resolving rejections
- D. Writing prescriptions
Correct answer: C. Entering insurance information and resolving rejections
40. The maximum annual amount a patient pays before full coverage is:
- A. Premium
- B. Co-pay
- C. Out-of-pocket maximum
- D. Step therapy limit
Correct answer: C. Out-of-pocket maximum
41. Tiered formularies categorize drugs based on:
- A. Color
- B. Strength
- C. Cost and coverage level
- D. Alphabetical order
Correct answer: C. Cost and coverage level
42. A patient assistance program (PAP):
- A. Hires personal nurses
- B. Offers discounts or free medications from manufacturers
- C. Tracks prescriptions
- D. Issues insurance cards
Correct answer: B. Offers discounts or free medications from manufacturers
43. Insurance claim processing time typically depends on:
- A. Patient illness
- B. Type of drug
- C. Real-time electronic systems
- D. Color of prescription
Correct answer: C. Real-time electronic systems
44. An insurance “formulary alternative” is:
- A. A brand-name drug
- B. A similar drug preferred by the plan
- C. A rejected drug
- D. A non-FDA product
Correct answer: B. A similar drug preferred by the plan
45. When should a pharmacist contact the insurer directly?
- A. To request lunch discounts
- B. To update patient allergies
- C. To resolve claim rejections or clarify coverage
- D. To increase co-pay
Correct answer: C. To resolve claim rejections or clarify coverage
46. Mail-order pharmacy is an option for:
- A. Emergency prescriptions
- B. Long-term maintenance medications
- C. Controlled substances
- D. Single-dose antibiotics
Correct answer: B. Long-term maintenance medications
47. What does “CMS” stand for?
- A. Clinical Medical Services
- B. Centers for Medicare & Medicaid Services
- C. Care Management Software
- D. Chronic Medication Solutions
Correct answer: B. Centers for Medicare & Medicaid Services
48. The DAW code on a claim indicates:
- A. The patient has no allergies
- B. Drug Adverse Warning
- C. Dispense As Written—no substitution allowed
- D. Denied Access Warning
Correct answer: C. Dispense As Written—no substitution allowed
49. If a medication is not listed in the formulary, it is considered:
- A. Preferred
- B. Covered
- C. Non-formulary
- D. Copay-free
Correct answer: C. Non-formulary
50. Accurate processing of prescription insurance claims improves:
- A. Marketing
- B. Patient access to therapy and reduces costs
- C. Drug development time
- D. Pharmacy branding
Correct answer: B. Patient access to therapy and reduces costs