Managed care pharmacy focuses on managing prescription drug benefits for populations to ensure safe, effective, and affordable medication use. This practice area involves work within health plans, pharmacy benefit managers (PBMs), and government agencies, focusing on formulary development, clinical quality programs, and benefit design. For PharmD students, understanding these principles is crucial for navigating the healthcare system and pursuing diverse career opportunities that shape patient access to medications.
1. What is the primary role of a Pharmacy Benefit Manager (PBM) in the U.S. healthcare system?
- To manufacture prescription medications
- To operate a chain of community pharmacies
- To manage prescription drug benefits on behalf of health plans and employers
- To regulate the approval of new drugs
Answer: To manage prescription drug benefits on behalf of health plans and employers
2. A tiered formulary is a common health plan coverage design where drugs are grouped to determine what?
- The patient’s out-of-pocket cost or cost-share
- The medication’s expiration date
- The pharmacy where the drug must be filled
- The color of the final tablet or capsule
Answer: The patient’s out-of-pocket cost or cost-share
3. The process by which a health plan evaluates new drugs for formulary inclusion, often using clinical and economic data, is primarily managed by the:
- Marketing and Sales Department
- Pharmacy and Therapeutics (P&T) Committee
- Human Resources Department
- Information Technology Department
Answer: The Pharmacy and Therapeutics (P&T) Committee
4. A Drug Utilization Review (DUR) program is designed to:
- Increase the sales of high-cost medications
- Identify and resolve potential medication-related problems like therapeutic duplications or drug interactions
- Pay pharmacies for dispensing medications
- Market new drugs directly to consumers
Answer: Identify and resolve potential medication-related problems like therapeutic duplications or drug interactions
5. What is a key objective of specialty pharmacy management within a managed care organization?
- To ensure all specialty drugs are available over-the-counter
- To manage the high costs and complex use of specialty pharmaceuticals
- To increase the number of prior authorizations for generic drugs
- To limit patient access to all specialty medications
Answer: To manage the high costs and complex use of specialty pharmaceuticals
6. The CMS Medicare 5-Star Quality Rating program is used to measure the performance of which types of plans?
- All employer-sponsored health plans
- Medicaid and Exchange plans only
- Medicare Advantage and Medicare Part D plans
- Direct-to-consumer pharmacy discount plans
Answer: Medicare Advantage and Medicare Part D plans
7. In a managed care context, “drug trend” refers to the:
- Popularity of a specific medication on social media
- Measure of the growth in spending for prescription drugs
- Process of discovering new medications
- Expiration date of a medication
Answer: Measure of the growth in spending for prescription drugs
8. A “prior authorization” is a managed care strategy that requires:
- The patient to pay for the medication in advance
- The pharmacy to order the medication from a specific wholesaler
- Justification from the prescriber to establish medical necessity before a drug will be covered
- The patient to try a brand-name drug before a generic is covered
Answer: Justification from the prescriber to establish medical necessity before a drug will be covered
9. Which of the following is a potential career opportunity for a pharmacist within a health plan or PBM?
- Working on formulary management
- Developing clinical quality programs
- Managing a mail-order pharmacy
- All of the above
Answer: All of the above
10. What is the main goal of a value-based contract between a health plan and a pharmaceutical manufacturer?
- To guarantee a fixed price for all drugs, regardless of outcome
- To link reimbursement for a drug to its clinical effectiveness or patient outcomes
- To exclusively promote the most expensive medications
- To eliminate the need for a pharmacy formulary
Answer: To link reimbursement for a drug to its clinical effectiveness or patient outcomes
11. A health plan’s list of covered medications is known as its:
- Invoice
- Manifest
- Formulary
- Directory
Answer: Formulary
12. HEDIS (Healthcare Effectiveness Data and Information Set) is a tool used by health plans to:
- Measure performance on important dimensions of care and service
- Calculate pharmacy reimbursement rates
- Design marketing campaigns for new members
- Negotiate drug rebates with manufacturers
Answer: Measure performance on important dimensions of care and service
13. In a typical tiered formulary, which tier would have the lowest patient cost-share?
- Tier 4 (Specialty Drugs)
- Tier 3 (Non-Preferred Brand Drugs)
- Tier 2 (Preferred Brand Drugs)
- Tier 1 (Generic Drugs)
Answer: Tier 1 (Generic Drugs)
14. A “plan sponsor” in managed care pharmacy is the:
- Entity, such as an employer or government program, that establishes the health plan for its members
- Pharmaceutical company that sponsors clinical trials
- Individual patient who receives the prescription
- Community pharmacy that dispenses the medication
Answer: The entity, such as an employer or government program, that establishes the health plan for its members
15. A retrospective DUR would involve reviewing medication use patterns:
- Before the prescription is dispensed
- At the point of sale in the pharmacy
- After the medication has been dispensed
- During the drug’s clinical trial phase
Answer: After the medication has been dispensed
16. What is a primary consideration when a managed care organization evaluates a new specialty drug for formulary placement?
- The color of the drug’s packaging
- Its high cost and the availability of clinical effectiveness data
- The ease of pronouncing the drug’s name
- The number of social media followers the manufacturer has
Answer: Its high cost and the availability of clinical effectiveness data
17. Medicare Part D provides coverage for:
- Inpatient hospital stays
- Outpatient prescription drugs
- Physician office visits
- Long-term nursing home care
Answer: Outpatient prescription drugs
18. A “pharmacy network” is a group of pharmacies that have:
- The same owner
- Contracted with a health plan or PBM to provide services to its members
- Agreed to only dispense brand-name drugs
- A shared computer system for processing all prescriptions
Answer: Contracted with a health plan or PBM to provide services to its members
19. Step therapy is a utilization management tool that requires a patient to:
- Try a more cost-effective drug before a more expensive drug in the same class is covered
- Attend physical therapy before any medication is covered
- Climb a set of stairs before picking up their prescription
- Fill their prescription at a specific time of day
Answer: Try a more cost-effective drug before a more expensive drug in the same class is covered
20. Which principle is fundamental to pharmacoeconomics, a field often used in managed care decision-making?
- Prescribing the newest drug available, regardless of cost
- Comparing the costs and consequences of different pharmaceutical products or interventions
- Ensuring that all drugs have the same price
- Ignoring the clinical outcomes associated with a drug
Answer: Comparing the costs and consequences of different pharmaceutical products or interventions
21. Rebates from pharmaceutical manufacturers to PBMs or health plans typically have what effect?
- They increase the final price the health plan pays for a drug
- They have no impact on the cost of medications
- They lower the net cost of a medication for the health plan
- They are passed directly to the patient at the pharmacy counter
Answer: They lower the net cost of a medication for the health plan
22. A Medication Therapy Management (MTM) program, particularly in Medicare, is designed to:
- Help patients optimize their medication use and improve health outcomes
- Encourage patients to take more medications
- Replace the need for a primary care physician
- Provide insurance coverage for over-the-counter products
Answer: Help patients optimize their medication use and improve health outcomes
23. The role of a managed care pharmacist differs from a traditional community pharmacist in that it focuses more on:
- The health outcomes of individual patients only
- Managing medication use and costs for entire populations of patients
- The physical act of dispensing prescriptions
- Compounding non-sterile preparations
Answer: Managing medication use and costs for entire populations of patients
24. In the pharmacy supply chain, the “wholesaler” typically:
- Manufactures the drugs
- Prescribes the drugs to patients
- Purchases drugs from manufacturers and distributes them to pharmacies
- Manages the patient’s prescription benefits
Answer: Purchases drugs from manufacturers and distributes them to pharmacies
25. A managed care organization might exclude a drug from its formulary if:
- It is the only drug available for a specific condition
- There are other, more cost-effective alternatives with similar clinical efficacy
- The drug is a generic medication
- The drug has no side effects
Answer: There are other, more cost-effective alternatives with similar clinical efficacy
26. The Affordable Care Act (ACA) led to the creation of what platform for individuals to purchase health insurance?
- Medicare
- The Department of Veterans Affairs
- Health Insurance Exchanges or Marketplaces
- Employer-sponsored plans
Answer: Health Insurance Exchanges or Marketplaces
27. What is a primary challenge associated with managing specialty drug benefits?
- These drugs are typically inexpensive and easy to administer
- The high cost per patient and the need for close monitoring
- There are too many pharmacies qualified to dispense them
- The lack of clinical data for these medications
Answer: The high cost per patient and the need for close monitoring
28. A prospective DUR occurs:
- One year after the medication is dispensed
- Before the prescription is dispensed to the patient
- During the drug manufacturing process
- Only for patients who are hospitalized
Answer: Before the prescription is dispensed to the patient
29. The main purpose of a health plan’s mail-order pharmacy option is to:
- Provide medications for acute, immediate-start therapies
- Encourage members to visit their local community pharmacy
- Dispense medications, often for chronic conditions, at a lower cost
- Eliminate the need for pharmacists in the dispensing process
Answer: Dispense medications, often for chronic conditions, at a lower cost
30. Which factor is LEAST likely to be considered by a P&T committee when evaluating a new drug?
- Clinical trial evidence of safety and efficacy
- Pharmacoeconomic analyses
- The color and design of the drug’s logo
- The availability of therapeutic alternatives
Answer: The color and design of the drug’s logo
31. The growth in spending on prescription drugs is driven by price increases and:
- A decrease in the number of prescriptions being written
- An increase in utilization (the number of prescriptions dispensed)
- The expiration of patents on many brand-name drugs
- A lack of new drugs coming to market
Answer: An increase in utilization (the number of prescriptions dispensed)
32. One of the goals of managed care is to improve quality of care. The CMS Star Ratings measure of “medication adherence” tracks how often patients:
- Switch to a different medication
- Pick up their prescriptions for chronic conditions like diabetes or hypertension
- Report a side effect
- Request a brand-name drug
Answer: Pick up their prescriptions for chronic conditions like diabetes or hypertension
33. What is a potential conflict of interest for a PBM?
- They aim to lower drug costs for their clients
- They may own their own mail-order and specialty pharmacies
- They employ pharmacists
- They use formularies to manage drug benefits
Answer: They may own their own mail-order and specialty pharmacies
34. A quantity limit is a utilization management tool that:
- Restricts the amount of a medication a patient can receive in a certain timeframe
- Requires the patient to pay 100% of the drug’s cost
- Ensures the patient receives a 90-day supply of all medications
- Limits the number of pharmacies a patient can use
Answer: Restricts the amount of a medication a patient can receive in a certain timeframe
35. A pharmacist working in managed care might be involved in designing a clinical program to:
- Improve adherence to statins in patients with cardiovascular disease
- Increase the sales of a specific over-the-counter product
- Compound non-sterile preparations for individual patients
- Manage the pharmacy’s daily inventory
Answer: Improve adherence to statins in patients with cardiovascular disease
36. A key difference between Medicaid and Medicare is that Medicaid is:
- A federal program exclusively for people aged 65 and older
- A program jointly funded by federal and state governments for low-income individuals
- A private insurance plan offered by employers
- A pharmacy discount card program
Answer: A program jointly funded by federal and state governments for low-income individuals
37. Formulary drug tiering and prior authorizations are strategies used by managed care to:
- Increase unnecessary drug spending
- Guide patients and prescribers toward more cost-effective therapies
- Make it impossible for patients to get any medication
- Eliminate the role of the pharmacist
Answer: Guide patients and prescribers toward more cost-effective therapies
38. What does “white bagging” refer to in the context of specialty pharmacy?
- A pharmacy dispenses a medication directly to the patient to take home
- A specialty pharmacy dispenses a physician-administered drug and ships it to the physician’s office for administration
- A physician purchases a drug directly from the manufacturer
- A patient receives a white bag with their prescription
Answer: A specialty pharmacy dispenses a physician-administered drug and ships it to the physician’s office for administration
39. A cost-effectiveness analysis is used in formulary decisions to compare two or more drugs by relating their costs to their:
- Marketing budgets
- Clinical outcomes, measured in natural units (e.g., life-years gained)
- Popularity among physicians
- Packaging design
Answer: Clinical outcomes, measured in natural units (e.g., life-years gained)
40. A pharmacist’s role in the pharmaceutical industry can involve interacting with managed care organizations to:
- Provide clinical data and economic information about their company’s products
- Dispense medications directly to patients
- Set the health plan’s premium rates
- Manage the P&T committee for the health plan
Answer: To provide clinical data and economic information about their company’s products
41. Which of the following is an example of a “medical benefit” drug that a managed care pharmacist might manage?
- An oral antibiotic picked up at a community pharmacy
- An injectable drug, like a chemotherapy agent, administered in a physician’s office
- Over-the-counter pain medication
- A bottle of insulin vials for home use
Answer: An injectable drug, like a chemotherapy agent, administered in a physician’s office
42. The primary goal of a health plan’s coverage design is to:
- Provide access to quality, cost-effective care for its members
- Cover every drug on the market without restrictions
- Make healthcare as expensive as possible
- Limit access to all preventive services
Answer: To provide access to quality, cost-effective care for its members
43. A managed care organization may use a “preferred” pharmacy network to:
- Prevent members from getting their prescriptions filled
- Direct members to pharmacies that have agreed to lower reimbursement rates or higher quality standards
- Ensure that all pharmacies in a state are included
- Increase the cost of medications for the health plan
Answer: To direct members to pharmacies that have agreed to lower reimbursement rates or higher quality standards
44. A concurrent DUR is performed:
- During the dispensing process, at the point of sale
- Weeks after the prescription has been dispensed
- Before the prescription is written by the doctor
- Only for patients over the age of 65
Answer: During the dispensing process, at the point of sale
45. One of the main reasons for the increasing drug trend in the U.S. is:
- The high price of new specialty medications
- A sharp decline in the number of prescriptions being filled
- The fact that most brand-name drugs have recently gone generic
- A lack of any new drugs being approved by the FDA
Answer: The high price of new specialty medications
46. Which entity would be most concerned with managing the prescription drug benefit for a large, self-insured company?
- The Food and Drug Administration (FDA)
- A Pharmacy Benefit Manager (PBM)
- The Centers for Disease Control and Prevention (CDC)
- A community pharmacy
Answer: A Pharmacy Benefit Manager (PBM)
47. A “carve-out” in managed care refers to:
- A type of surgical procedure
- The process of separating a specific benefit, like the pharmacy or mental health benefit, to be managed by a specialty vendor
- A method for calculating patient copayments
- A type of prior authorization form
Answer: The process of separating a specific benefit, like the pharmacy or mental health benefit, to be managed by a specialty vendor
48. What is the fundamental purpose of cost-sharing (e.g., copays, coinsurance) for patients?
- To make patients share in the cost of their healthcare services
- To eliminate all costs for the health plan
- To ensure that all healthcare is free for the patient
- To increase the time it takes to get a prescription filled
Answer: To make patients share in the cost of their healthcare services
49. A pharmacist working in a managed care setting needs a strong understanding of:
- Clinical therapeutics and evidence-based medicine
- Pharmacoeconomics and data analysis
- The healthcare delivery system
- All of the above
Answer: All of the above
50. The overarching principle of managed care pharmacy is to achieve a balance between:
- Cost, quality, and access to care
- Increasing drug costs and limiting all access
- Marketing and clinical evidence
- The roles of the pharmacist and the technician
Answer: Cost, quality, and access to care
I am a Registered Pharmacist under the Pharmacy Act, 1948, and the founder of PharmacyFreak.com. I hold a Bachelor of Pharmacy degree from Rungta College of Pharmaceutical Science and Research. With a strong academic foundation and practical knowledge, I am committed to providing accurate, easy-to-understand content to support pharmacy students and professionals. My aim is to make complex pharmaceutical concepts accessible and useful for real-world application.
Mail- Sachin@pharmacyfreak.com