Question

Figure 4

Patient/Service	Service Date(s)	(A) Total Charge	Allowed Amount	(B) Not Payable by Plan	Plan Paid Amount
White, Jane
Office Visit	02/17/200*	65.00	56.00	10.00 CP	46.00 (100%)
X-Ray	02/17/200*	350.00	268.00	250.00 DD 3.60 CI	14.40 (80%)
Lab	02/17/200*	35.00	20.00	15.00 CP	5.00 (100%)
Totals

Codes and Remarks

CI Coinsurance

CP Copayment

DD Deductible

Had the patient (subscriber) met the deductible prior to the first service included on this document (using Figure 4)?

a	Yes, as evidenced by the plan’s $250 payment for the deductible

b	Yes, as evidenced by the application of the copayment provision

c	No, as evidenced by the patient’s required payment of $250

d

Cannot be determined

Per Figure 4, after the payment of the third-party payer, how much will the patient have to pay (for all three of these services together)? You may assume this in an in-network provider.                                   

a

$65.40

b

$250.00

c

$278.60

d $344.00

Which type of prescription drug is likely to be the least costly for health plan members using a health plan with a tiered drug benefit (using Figure 4)?

a	Generic medication

b	Formulary medication for which a generic is available

c	Formulary medication for which no generic is available

d	Non- Formulary medication

Answer 1

1. Had the patient (subscriber) met the deductible prior to the first service included on this document (using Figure 4)?

Ans. (a) Yes, as evidenced by the plans $250 payment for the deductibles.

2. Per Figure 4, after the payment of the third-party payer, how much will the patient have to pay (for all three of these services together)? You may assume this in an in-network provider.

Ans. (a) $65.40

3. Which type of prescription drug is likely to be the least costly for health plan members using a health plan with a tiered drug benefit (using Figure 4)?

Ans. (a) Generic medication