QUESTION: 89

The Gladspell HMO has contracted with the Ellysium Hospital to provide subacute care to its plan members. Gladspell pays Ellysium by using a per diem reimbursement method.

If the Ellysium subacute care unit is typical of most hospital-based subacute skilled nursing units, then this unit could be used for patients who no longer need to be in the hospital's acute care unit but who still require

Daily medical care and monitoring
Regular rehabilitative therapy
Respiratory therapy
All of the above

Answer(s): D

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QUESTION: 90

The method of pharmaceutical reimbursement under which a plan member obtains prescription drugs from participating network pharmacies by presenting proper identification and paying a specified copayment is the

Wholesale acquisition cost (WAC) approach
Reimbursement approach
Service approach
Cognitive approach

Answer(s): C

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QUESTION: 91

In most health plan pharmacy networks, the cost component of the reimbursement formula is based on the average wholesale price (AWP). One true statement about the AWP for prescription drugs is that

AWPs tend to vary widely from region to region of the United States
The AWP is often substantially higher than the actual price the pharmacy pays for prescription drugs
A health plan's contracted reimbursement to a pharmacy for prescription drugs is typically the 39 AWP plus a percentage, such as 5%
The AWP usually is lower than the estimated acquisition cost (EAC) for most prescription drugs

Answer(s): B

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QUESTION: 92

In the paragraph below, two statements each contain a pair of terms enclosed in parentheses. Determine which term correctly completes each statement. Then select the answer choice that contains the two terms you have chosen.

A formulary lists the drugs and treatment protocols that are considered to be the preferred therapy for a given managed population. The Fairfax Health Plan uses the type of formulary which covers drugs that are on its preferred list as well as drugs that are not on its preferred list. This information indicates that Fairfax uses the (closed / open) formulary method. In using the formulary approach to pharmacy benefits management, Fairfax most likely experiences (higher / lower) costs for its members' prescription drugs than it would if it did not use a formulary.

closed / higher
closed / lower
open / higher
open / lower

Answer(s): D

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QUESTION: 92

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