Question

1.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?

Non-Formulary generic medication

Formulary generic medication

Formulary brand medication

Non- Formulary brand medication

2.Which of the following are not out-of-pocket costs for a health plan member?

Allowed amount

Health insurance prem

Co payments

Co insurance

3.In which type of reimbursement methodology does the medical provider have the greatest degree of financial risk?

Capitated payment

Global payment

Fee of service

Bundled payment

Plan Information:

Premium	$50 / month
Annual Medical Deductible	$1,000^#
Physician services (PCP and Specialist)	$15
Inpatient services	20%*
Annual Medical Out of Pocket Maximum	$3,000^
Annual Pharmacy Deductible	$500#
Pharmacy	$30* / Rx/month

* deductible must be met before coverage

^ amounts paid toward the deductible ARE included in calculation of out of pocket maximum. Copayments for services not included in the deductible are NOT.

# separate deductibles for medical services and pharmacy

Utilization Information:

Alexandra used the following health care services over the course of the year. Her health plan’s allowed charge (contract/negotiated) amounts for each service are included for your reference:

Services utilized	Annual total cost (allowed amount)
10 physician office visits at $100 each	$1,000
10 day hospitalization	$51,000
1 Rx per month at $50/month	$600

4.What would Alexandra pay for all 10 physician office visits if they all occurred prior to her hospitalization?

1000

1500

150

3000

5.What would Alexandra pay for her hospitalization if it occurred prior to her physician visit?

1000

3000

51000

11000

6.If she receives all of the services listed above, will Alexandra have met her medical deductible for this plan year?

Yes

No

7.If Alexandra has received all of the services listed above, will she have met her pharmacy deductible for the year?

Yes

no

Answer 1

1. Formulary generic medication

Generic medicines have the lowest copay as they are in tire one. A formulary is a group of drugs selected by concerned people for their safety and efficiency.

2. Allowed amount

Deductibles Or health insurance premiums, Co-payments, Coinsurance are out of pocket expenses

3. Capitated payment

It is retrospective payment where the health insurance company have the greatest degree of risk?

4. 1000

5. 51000

6. Yes

7. No

It should cross pharmacy deductible for the year