Answer Key- AHIP - Final examination Page 1 of 15 2/1/2026
AHIP - Final examination
Mr. Zachow has a right to request a formulary exception to obtain coverage for his Part D drug. He or his
physician could obtain the standardized request form on the plan's website, fill it out, and submit it to
his plan.
Mr. Zachow has a condition for which three drugs are available. He has tried two but had an allergic
reaction to them. Only the third drug works for him and it is not on his Part D plan's formulary. What
could you tell him to do?
The POS option might be a good solution for him as it will allow him to visit out-of-network providers,
generally without prior approval. However, he should be aware that it is likely he will have to pay higher
cost-sharing for services from out-of-network providers.
Mr. Polanski likes the cost of an HMO plan available in his area, but would like to be able to visit one or
two doctors who aren't participating providers. He wants to know if the Point of Service (POS) option
available with some HMOs will be of any help in this situation. What should you tell him?
You can offer to review the plans appeal process to help him ask the plan to review the coverage
decision.
Mr. Barker had surgery recently and expected that he would have certain services and items covered by
the plan with minimal out-of-pocket costs because his MA-PD coverage has been very good. However,
when he received the bill, he was surprised to see large charges in excess of his maximum out-of-pocket
limit that included a number of services and items he thought would be fully covered. He called you to
ask what he could do? What could you tell him?
a. Yes. All SNPs are required to provide Part D coverage for prescription drugs.
b. Yes, but only if she qualifies for Part D prescription drug coverage under her state Medicaid program.
Page 1 AHIP - Final examination.pdf AHIP - Final examination.pdf
, Answer Key- AHIP - Final examination Page 2 of 15 2/1/2026
c. No. Medicare beneficiaries who enroll in an SNP must always obtain their drug coverage through a
stand-alone Part D Medicare prescription drug plan that they sign up for independent of their
enrollment in the SNP.
d. Maybe. Some SNPs offer Part D coverage for prescription drugs and some do not.
= ?????
Ms. Stuart has heard about a special needs plan (SNP) that one of her friends is enrolled in and is
interested in that product. She wants to be sure she also has coverage for prescription drugs. Would she
be able to obtain drug coverage if she enrolled in the SNP?
II. All data elements required to complete an enrollment request must be captured.
III. The process must include a clear and distinct step that requires the applicant to activate an "Enroll
Now" or "I Agree" type of button or tool.
Phiona works in the IT Department of BestCare Health Plan. Phiona is placed in charge of BestCare's
efforts to facilitate electronic enrollment in its Medicare Advantage plans. In setting up the enrollment
site, which of the following must Phiona consider?
Step therapy involves using one or more lower priced drugs before trying a more expensive drug when
all are used to treat the same condition.
Ms. Lewis understands that Medicare prescription drug plans may use various methods to control the
use of specific drugs. She has heard about a technique called "step therapy" and is wondering if you can
explain what that is. What should you tell her?
He may receive health care services from ANY doctor allowed to bill Medicare, as long as he shows the
doctor the plan's identification card and the doctor agrees to accept the PFFS plan's payment terms and
conditions, which could include balance billing.
Mr. Gomez notes that a Private Fee-for-Service (PFFS) plan available in his area has an attractive
premium. He wants to know if he must use doctors in a network as his current HMO plan requires him
to do. What should you tell him?
Page 2 AHIP - Final examination.pdf AHIP - Final examination.pdf
AHIP - Final examination
Mr. Zachow has a right to request a formulary exception to obtain coverage for his Part D drug. He or his
physician could obtain the standardized request form on the plan's website, fill it out, and submit it to
his plan.
Mr. Zachow has a condition for which three drugs are available. He has tried two but had an allergic
reaction to them. Only the third drug works for him and it is not on his Part D plan's formulary. What
could you tell him to do?
The POS option might be a good solution for him as it will allow him to visit out-of-network providers,
generally without prior approval. However, he should be aware that it is likely he will have to pay higher
cost-sharing for services from out-of-network providers.
Mr. Polanski likes the cost of an HMO plan available in his area, but would like to be able to visit one or
two doctors who aren't participating providers. He wants to know if the Point of Service (POS) option
available with some HMOs will be of any help in this situation. What should you tell him?
You can offer to review the plans appeal process to help him ask the plan to review the coverage
decision.
Mr. Barker had surgery recently and expected that he would have certain services and items covered by
the plan with minimal out-of-pocket costs because his MA-PD coverage has been very good. However,
when he received the bill, he was surprised to see large charges in excess of his maximum out-of-pocket
limit that included a number of services and items he thought would be fully covered. He called you to
ask what he could do? What could you tell him?
a. Yes. All SNPs are required to provide Part D coverage for prescription drugs.
b. Yes, but only if she qualifies for Part D prescription drug coverage under her state Medicaid program.
Page 1 AHIP - Final examination.pdf AHIP - Final examination.pdf
, Answer Key- AHIP - Final examination Page 2 of 15 2/1/2026
c. No. Medicare beneficiaries who enroll in an SNP must always obtain their drug coverage through a
stand-alone Part D Medicare prescription drug plan that they sign up for independent of their
enrollment in the SNP.
d. Maybe. Some SNPs offer Part D coverage for prescription drugs and some do not.
= ?????
Ms. Stuart has heard about a special needs plan (SNP) that one of her friends is enrolled in and is
interested in that product. She wants to be sure she also has coverage for prescription drugs. Would she
be able to obtain drug coverage if she enrolled in the SNP?
II. All data elements required to complete an enrollment request must be captured.
III. The process must include a clear and distinct step that requires the applicant to activate an "Enroll
Now" or "I Agree" type of button or tool.
Phiona works in the IT Department of BestCare Health Plan. Phiona is placed in charge of BestCare's
efforts to facilitate electronic enrollment in its Medicare Advantage plans. In setting up the enrollment
site, which of the following must Phiona consider?
Step therapy involves using one or more lower priced drugs before trying a more expensive drug when
all are used to treat the same condition.
Ms. Lewis understands that Medicare prescription drug plans may use various methods to control the
use of specific drugs. She has heard about a technique called "step therapy" and is wondering if you can
explain what that is. What should you tell her?
He may receive health care services from ANY doctor allowed to bill Medicare, as long as he shows the
doctor the plan's identification card and the doctor agrees to accept the PFFS plan's payment terms and
conditions, which could include balance billing.
Mr. Gomez notes that a Private Fee-for-Service (PFFS) plan available in his area has an attractive
premium. He wants to know if he must use doctors in a network as his current HMO plan requires him
to do. What should you tell him?
Page 2 AHIP - Final examination.pdf AHIP - Final examination.pdf
