QUESTION: 93

The following statements are about the inclusion of unified pharmacy benefits in health plan healthcare packages. Select the answer choice containing the correct statement.

When pharmacy benefits management is incorporated into an health plan's operations as a unified benefit, the health plan establishes pharmacy networks, but a pharmacy benefits management (PBM) company manages their operations.
Under a unified pharmacy benefit, an health plan cannot use mail-order services to provide drugs to its members.
Compared to programs that do not manage pharmacy benefits in-house, unified pharmacy benefits programs typically give health plans more control over patient access to prescription drugs.
Compared to programs that do not manage pharmacy benefits in-house, unified pharmacy benefits programs make drug therapy interventions for plan members more difficult.

Answer(s): C

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QUESTION: 94

The following statements can correctly be made about the advantages and disadvantages to an health plan of using the various delivery options for pharmacy services.

A disadvantage of using open pharmacy networks is that the health plan's control over costs is limited to setting reimbursement levels.
An advantage of using performance-based systems is that they tend to increase participation in the health plan's pharmacy network.
A disadvantage of using customized pharmacy networks is that these networks typically can be implemented only in companies with fewer than 500 employees.
All of these statements are correct.

Answer(s): A

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The Walton Health Plan uses the fee-for-service pharmaceutical reimbursement approach known as the maximum allowable cost (MAC) method. If Walton's MAC list specifies a cost of 8 cents per tablet for a particular drug but the participating pharmacy pays 10 cents per tablet for the drug, then Walton will be obligated to reimburse the pharmacy for

8 cents per tablet, but the pharmacy can bill the subscriber for the remaining 2 cents per tablet
8 cents per tablet, and the pharmacy cannot bill the subscriber for the remaining 2 cents per tablet
10 cents per tablet, but the pharmacy must refund the extra 2 cents per tablet to the subscriber
10 cents per tablet, and the pharmacy is not required to refund the extra 2 cents per tablet to the subscriber

Answer(s): B

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QUESTION: 96

One reason that an health plan would want to use the actual acquisition cost (AAC) pricing system to calculate its drug costs is that, of the systems commonly used to calculate drug costs, the AAC system

Provides the lowest level of cost for the health plan
Most closely represents what pharmacies are actually charged for prescription drugs
Offers the best control over multiple-source pharmaceutical products
Is the least expensive pricing system for the health plan to implement

Answer(s): A

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