1
AHIP FINAL EXAMINATION ACTUAL 2026-27
LATEST VERSION WITH QUESTIONS AND
CORRECT SOLUTIONS
Mr. Lopez has heard that he can sign up for a product called "Medicare
Advantage" but is not sure about what type of plan designs are
available through this program. What Medicare Advantage program? -
They are Medicare health plans such as HMOs, PPOs, should you tell
him about the types of health plans that are available through the PFFS,
and MSAs.
Mr. Sanchez has just turned 65 and is entitled to Part A but has not
enrolled in Part B because he has coverage through an employer plan. If
he wants to enroll in a Medicare Advantage plan, what will he have to
do? - He will have to enroll in Part B.
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? - 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. Bickford did not quite qualify for the extra help low-income subsidy
under the Medicare Part D Prescription Drug program and he is
wondering if there is any other option he has for obtaining help with his
considerable drug costs. What should you tell him? - He could check
with the manufacturers of his medications to see if they offer an
,2
assistance program to help people with limited means to obtain the
medications they need. Alternatively, he could check to see whether
his state has a pharmacy assistance program to help him with his
expenses.
Mr. and Mrs. Vaughn both take a specialized multivitamin prescription
each day. Mr. Vaughn takes a prescription for helping to regrow his
hair. They are anxious to have their Medicare prescription drug plan
cover these drug needs. What should you tell them? - Medicare
prescription drug plans are not permitted to cover the prescription
medications the Vaughns are interested in under Part D coverage,
however, plans may cover them as supplemental benefits and the
Vaughn's could look into that possibility.
Mr. Wingate is a newly enrolled Medicare Part D beneficiary and one of
your clients. In addition to drugs on his plan's formulary he takes
several other medications. These include a prescription drug not on his
plan's formulary, over-the-counter medications for colds and allergies,
vitamins, and drugs from an Internet-based Canadian pharmacy to
promote hair growth and reduce joint swelling. His neighbor recently
told him about a concept called TrOOP and he asks you if any of his
other medications could count toward TrOOP should he ever reach the
Part D catastrophic limit. What should you say?
- None of the costs of Mr. Wingate's other medications would currently
count toward TrOOP but he may wish to ask his plan for an exception to
cover the prescription not on its formulary.
Ms. Edwards is enrolled in a Medicare Advantage plan that includes
prescription drug plan (PDP) coverage. She is traveling and wishes to fill
two of the prescriptions that she has lost. How would you advise her? -
She may fill prescriptions for covered drugs at non-network
pharmacies, but likely at a higher cost than paid at an in-network
pharmacy.
Mrs. Lopez is enrolled in a cost plan for her Medicare benefits. She has
recently lost creditable coverage previously available through her
,3
husband's employer. She is interested in enrolling in a Medicare Part D
prescription drug plan (PDP). What should you tell her? - If a Part D
benefit is offered through her plan she may choose to enroll in that
plan or a standalone PDP.
Mrs. Allen has a rare condition for which two different brand name
drugs are the only available treatment. She is concerned that since no
generic prescription drug is available and these drugs are very high
cost, she will not be able to find a Medicare Part D prescription drug
plan that covers either one of them. What should you tell her? -
Medicare prescription drug plans are required to cover drugs in each
therapeutic category. She should be able to enroll in a Medicare
prescription drug plan that covers the medications she needs.
Mrs. Quinn has just turned 65, is in excellent health and has a relatively
high income. She uses no medications and sees no reason to spend
money on a Medicare prescription drug plan if she does not need the
coverage. She currently does not have creditable coverage. What could
you tell her about the implications of such a decision? -
, 4
If she does not sign up for a Medicare prescription drug plan as soon as
she is eligible to do so, and if she does sign up at a later date, her
premium will be permanently increased by 1% of the national average
premium for every month that she was not covered.
Mr. Shultz was still working when he first qualified for Medicare. At
that time, he had employer group coverage that was creditable. During
his initial Part D eligibility period, he decided not to enroll because he
was satisfied with his drug coverage. It is now a year later and Mr.
Shultz has lost his employer group coverage within the last two weeks.
How would you advise him? - Mr. Schultz should enroll in a Part D plan
before he has a 63-day break in coverage in order to avoid a premium
penalty.
Mrs. Mulcahy, age 65, is concerned that she may not qualify for
enrollment in a Medicare prescription drug plan because, although she
is entitled to Part A, she is not enrolled under Medicare Part B. What
should you tell her? - An individual who is entitled to Part A or enrolled
under Part B is eligible to enroll in a Medicare prescription drug plan.
As long as Mrs. Mulcahy is entitled to Part A, she does not need to
enroll under Part B before enrolling in a prescription drug plan.
What types of tools can Medicare Part D prescription drug plans use
that affect the way their enrollees can access medications? - Part D
plans do not have to cover all medications. As a result, their
formularies, or lists of covered drugs, will vary from plan to plan. In
addition, they can use cost containment techniques such as tiered co-
payments and prior authorization.
All plans must cover at least the standard Part D coverage or its
actuarial equivalent. Which of the following statements best describes
some of the costs a beneficiary would incur for prescription drugs
under the standard coverage? - Standard Part D coverage would
require payment of an annual deductible, and once past the
catastrophic coverage threshold, the beneficiary pays whichever is
greater of either the co-pays for generic and brand name drugs or
AHIP FINAL EXAMINATION ACTUAL 2026-27
LATEST VERSION WITH QUESTIONS AND
CORRECT SOLUTIONS
Mr. Lopez has heard that he can sign up for a product called "Medicare
Advantage" but is not sure about what type of plan designs are
available through this program. What Medicare Advantage program? -
They are Medicare health plans such as HMOs, PPOs, should you tell
him about the types of health plans that are available through the PFFS,
and MSAs.
Mr. Sanchez has just turned 65 and is entitled to Part A but has not
enrolled in Part B because he has coverage through an employer plan. If
he wants to enroll in a Medicare Advantage plan, what will he have to
do? - He will have to enroll in Part B.
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? - 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. Bickford did not quite qualify for the extra help low-income subsidy
under the Medicare Part D Prescription Drug program and he is
wondering if there is any other option he has for obtaining help with his
considerable drug costs. What should you tell him? - He could check
with the manufacturers of his medications to see if they offer an
,2
assistance program to help people with limited means to obtain the
medications they need. Alternatively, he could check to see whether
his state has a pharmacy assistance program to help him with his
expenses.
Mr. and Mrs. Vaughn both take a specialized multivitamin prescription
each day. Mr. Vaughn takes a prescription for helping to regrow his
hair. They are anxious to have their Medicare prescription drug plan
cover these drug needs. What should you tell them? - Medicare
prescription drug plans are not permitted to cover the prescription
medications the Vaughns are interested in under Part D coverage,
however, plans may cover them as supplemental benefits and the
Vaughn's could look into that possibility.
Mr. Wingate is a newly enrolled Medicare Part D beneficiary and one of
your clients. In addition to drugs on his plan's formulary he takes
several other medications. These include a prescription drug not on his
plan's formulary, over-the-counter medications for colds and allergies,
vitamins, and drugs from an Internet-based Canadian pharmacy to
promote hair growth and reduce joint swelling. His neighbor recently
told him about a concept called TrOOP and he asks you if any of his
other medications could count toward TrOOP should he ever reach the
Part D catastrophic limit. What should you say?
- None of the costs of Mr. Wingate's other medications would currently
count toward TrOOP but he may wish to ask his plan for an exception to
cover the prescription not on its formulary.
Ms. Edwards is enrolled in a Medicare Advantage plan that includes
prescription drug plan (PDP) coverage. She is traveling and wishes to fill
two of the prescriptions that she has lost. How would you advise her? -
She may fill prescriptions for covered drugs at non-network
pharmacies, but likely at a higher cost than paid at an in-network
pharmacy.
Mrs. Lopez is enrolled in a cost plan for her Medicare benefits. She has
recently lost creditable coverage previously available through her
,3
husband's employer. She is interested in enrolling in a Medicare Part D
prescription drug plan (PDP). What should you tell her? - If a Part D
benefit is offered through her plan she may choose to enroll in that
plan or a standalone PDP.
Mrs. Allen has a rare condition for which two different brand name
drugs are the only available treatment. She is concerned that since no
generic prescription drug is available and these drugs are very high
cost, she will not be able to find a Medicare Part D prescription drug
plan that covers either one of them. What should you tell her? -
Medicare prescription drug plans are required to cover drugs in each
therapeutic category. She should be able to enroll in a Medicare
prescription drug plan that covers the medications she needs.
Mrs. Quinn has just turned 65, is in excellent health and has a relatively
high income. She uses no medications and sees no reason to spend
money on a Medicare prescription drug plan if she does not need the
coverage. She currently does not have creditable coverage. What could
you tell her about the implications of such a decision? -
, 4
If she does not sign up for a Medicare prescription drug plan as soon as
she is eligible to do so, and if she does sign up at a later date, her
premium will be permanently increased by 1% of the national average
premium for every month that she was not covered.
Mr. Shultz was still working when he first qualified for Medicare. At
that time, he had employer group coverage that was creditable. During
his initial Part D eligibility period, he decided not to enroll because he
was satisfied with his drug coverage. It is now a year later and Mr.
Shultz has lost his employer group coverage within the last two weeks.
How would you advise him? - Mr. Schultz should enroll in a Part D plan
before he has a 63-day break in coverage in order to avoid a premium
penalty.
Mrs. Mulcahy, age 65, is concerned that she may not qualify for
enrollment in a Medicare prescription drug plan because, although she
is entitled to Part A, she is not enrolled under Medicare Part B. What
should you tell her? - An individual who is entitled to Part A or enrolled
under Part B is eligible to enroll in a Medicare prescription drug plan.
As long as Mrs. Mulcahy is entitled to Part A, she does not need to
enroll under Part B before enrolling in a prescription drug plan.
What types of tools can Medicare Part D prescription drug plans use
that affect the way their enrollees can access medications? - Part D
plans do not have to cover all medications. As a result, their
formularies, or lists of covered drugs, will vary from plan to plan. In
addition, they can use cost containment techniques such as tiered co-
payments and prior authorization.
All plans must cover at least the standard Part D coverage or its
actuarial equivalent. Which of the following statements best describes
some of the costs a beneficiary would incur for prescription drugs
under the standard coverage? - Standard Part D coverage would
require payment of an annual deductible, and once past the
catastrophic coverage threshold, the beneficiary pays whichever is
greater of either the co-pays for generic and brand name drugs or
