2026 AHIP MODULE 3 PRACTICE EXAM MEDICARE PART D
PRESCRIPTION DRUG COVERAGE: ELIGIBILITY, BENEFITS,
FORMULARIES, COST SHARING,
1. Regarding Part D eligibility, Which conclusion is correct?
A. Both Part A and Part B are always required
B. A person generally may enroll in Part D if entitled to Part A or enrolled in Part B and residing in the plan
service area
C. Medigap is required
D. Only MA enrollees may get Part D
Correct Answer: B. A person generally may enroll in Part D if entitled to Part A or enrolled in Part B and
residing in the plan service area
Rationale: Part D eligibility generally requires entitlement to Part A or enrollment in Part B, along with residence
and other applicable eligibility requirements.
2. A beneficiary is comparing several Part D statements involving Quantity limits. Which statement should
be selected as the accurate one?
A. It is a premium surcharge
B. It bans generics
C. It restricts the number of doctors a person may see
D. A quantity limit restricts the amount of a drug the plan will cover over a specified period unless an exception is
approved
Correct Answer: D. A quantity limit restricts the amount of a drug the plan will cover over a specified period
unless an exception is approved
Rationale: Quantity limits are formulary controls on the covered amount or frequency of a
medication.
3. Martha is reviewing Medicare coverage during a one-on-one appointment and asks about Covered
insulin cost sharing. Which statement is most accurate?
A. For 2026, covered insulin cost sharing for a month supply is capped at the lesser of $35, 25% of the maximum
fair price when applicable, or 25% of the plan negotiated price
B. No federal insulin rule applies to Part D
C. Always exactly $100
D. Insulin is excluded from Part D
Correct Answer: A. For 2026, covered insulin cost sharing for a month supply is capped at the lesser of $35,
25% of the maximum fair price when applicable, or 25% of the plan negotiated price
Rationale: The IRA limits beneficiary cost sharing for covered insulin products; in 2026 the cap uses the
lesser-of calculation specified by CMS.
4. A pharmacist and a beneficiary are trying to apply current 2026 Part D rules to Part D late enrollment
penalty. Which interpretation is correct?
A. The penalty applies only after 5 years
B. The trigger is 7 days
C. A person may owe a Part D late enrollment penalty after going 63 consecutive days or more without
Part D or other creditable drug coverage after becoming eligible, absent an exception
D. The penalty is a one-time $10 fee
Correct Answer: C. A person may owe a Part D late enrollment penalty after going 63 consecutive days or more
without Part D or other creditable drug coverage after becoming eligible, absent an exception
Rationale: The Part D late enrollment penalty can apply after a coverage gap of 63 consecutive days or more
without creditable prescription drug coverage.
5. Regarding ACIP vaccines, Which response best applies?
A. They are excluded from Part D
B. They always require 20% coinsurance
C. Part D-covered adult vaccines recommended by ACIP are available without enrollee cost sharing
D. Only flu vaccine can be covered
,Correct Answer: C. Part D-covered adult vaccines recommended by ACIP are available without enrollee cost
sharing
Rationale: The IRA eliminated cost sharing for recommended adult vaccines covered under Part D.
6. A beneficiary is comparing several Part D statements involving Part D eligibility. Which statement
should be selected as the accurate one?
A. A person generally may enroll in Part D if entitled to Part A or enrolled in Part B and residing in the plan
service area
B. Both Part A and Part B are always required
C. Medigap is required
D. Only MA enrollees may get Part D
Correct Answer: A. A person generally may enroll in Part D if entitled to Part A or enrolled in Part B and
residing in the plan service area
Rationale: Part D eligibility generally requires entitlement to Part A or enrollment in Part B, along with residence
and other applicable eligibility requirements.
7. Victor is reviewing Medicare coverage while reviewing Medicare choices with a licensed agent and asks
about Creditable drug coverage. Which action or explanation is most appropriate?
A. It means any discount card
B. It guarantees no premium
C. It is the same as Medigap
D. Creditable coverage is expected to pay, on average, at least as much as standard Medicare drug coverage and
can help a person avoid a Part D late penalty
Correct Answer: D. Creditable coverage is expected to pay, on average, at least as much as standard Medicare
drug coverage and can help a person avoid a Part D late penalty
Rationale: Creditable prescription coverage is important when deciding whether to delay Part D enrollment
because it affects late-enrollment penalty exposure.
8. A pharmacist and a beneficiary are trying to apply current 2026 Part D rules to Prior authorization.
Which interpretation is correct?
A. It is the same as a deductible
B. Prior authorization requires plan approval or specified criteria before coverage of certain prescriptions
C. It permanently removes the drug from the formulary
D. It means the drug is automatically free
Correct Answer: B. Prior authorization requires plan approval or specified criteria before coverage of certain
prescriptions
Rationale: Prior authorization is a utilization-management tool used to confirm coverage criteria before payment.
9. Regarding True out-of-pocket, Which statement best resolves the question?
A. TrOOP is the set of qualifying costs that count toward the beneficiary Part D annual out-of-pocket threshold
B. It includes the plan premium
C. It is the Part B deductible
D. It means total retail drug price only
Correct Answer: A. TrOOP is the set of qualifying costs that count toward the beneficiary
Part D annual out-of-pocket threshold
Rationale: TrOOP rules determine which beneficiary and qualifying third-party payments count toward the Part
D OOP threshold.
10. A beneficiary is comparing several Part D statements involving Formulary exception. Which statement
should be selected as the accurate one?
A. No exceptions are permitted under Part D
B. An enrollee or prescriber may request a formulary or tiering exception when applicable plan criteria are met
C. Exceptions automatically waive the premium
D. Only the pharmacy can appeal
Correct Answer: B. An enrollee or prescriber may request a formulary or tiering exception when applicable plan
criteria are met
Rationale: Part D provides a coverage-determination and exceptions process for nonformulary drugs and certain
utilization or tiering issues.
, 11. Thomas is reviewing Medicare coverage after moving to a new county and asks about Catastrophic cost
sharing. What should the beneficiary be told?
A. The enrollee pays 25%
B. The enrollee pays 5%
C. The deductible restarts
D. After reaching the 2026 Part D out-of-pocket threshold, the enrollee has no cost sharing for covered
Part D drugs for the rest of the year
Correct Answer: D. After reaching the 2026 Part D out-of-pocket threshold, the enrollee has no cost sharing for
covered Part D drugs for the rest of the year
Rationale: Under the redesigned Part D benefit, beneficiary cost sharing is $0 in the catastrophic phase.
12. A pharmacist and a beneficiary are trying to apply current 2026 Part D rules to Extra Help. Which
interpretation is correct?
A. It eliminates the need to enroll in drug coverage
B. It is a Part A hospital subsidy only
C. Extra Help reduces qualifying beneficiaries Part D premiums and prescription cost sharing
D. It is available regardless of income/resources with no criteria
Correct Answer: C. Extra Help reduces qualifying beneficiaries Part D premiums and prescription cost sharing
Rationale: The Low-Income Subsidy helps eligible beneficiaries with Part D costs.
13. Regarding Payment Plan effect, How should this situation be interpreted?
A. It substitutes for Extra Help
B. It increases the OOP cap
C. It converts all drug costs to zero
D. Using the Medicare Prescription Payment Plan does not reduce the total annual out-of-pocket amount owed for
covered drugs; it spreads payments over time
Correct Answer: D. Using the Medicare Prescription Payment Plan does not reduce the total annual
out-of-pocket amount owed for covered drugs; it spreads payments over time
Rationale: The program is a payment-smoothing mechanism, not an additional drug subsidy.
14. A beneficiary is comparing several Part D statements involving 2026 Part D deductible. Which
statement should be selected as the accurate one?
A. $2,100
B. $590
C. $615 is the maximum standard deductible for 2026
D. $283
Correct Answer: C. $615 is the maximum standard deductible for 2026
Rationale: CMS set the 2026 defined standard Part D deductible at $615.
15. Denise is reviewing Medicare coverage during a one-on-one appointment and asks about True
out-of-pocket. Which statement is most accurate?
A. It means total retail drug price only
B. TrOOP is the set of qualifying costs that count toward the beneficiary Part D annual out-of-pocket threshold
C. It includes the plan premium
D. It is the Part B deductible
Correct Answer: B. TrOOP is the set of qualifying costs that count toward the beneficiary
Part D annual out-of-pocket threshold
Rationale: TrOOP rules determine which beneficiary and qualifying third-party payments count toward the Part
D OOP threshold.
16. A pharmacist and a beneficiary are trying to apply current 2026 Part D rules to 2026 OOP threshold.
Which interpretation is correct?
A. $2,100 is the 2026 annual Part D out-of-pocket threshold
B. $8,300
C. $615
D. $2,000
Correct Answer: A. $2,100 is the 2026 annual Part D out-of-pocket threshold
PRESCRIPTION DRUG COVERAGE: ELIGIBILITY, BENEFITS,
FORMULARIES, COST SHARING,
1. Regarding Part D eligibility, Which conclusion is correct?
A. Both Part A and Part B are always required
B. A person generally may enroll in Part D if entitled to Part A or enrolled in Part B and residing in the plan
service area
C. Medigap is required
D. Only MA enrollees may get Part D
Correct Answer: B. A person generally may enroll in Part D if entitled to Part A or enrolled in Part B and
residing in the plan service area
Rationale: Part D eligibility generally requires entitlement to Part A or enrollment in Part B, along with residence
and other applicable eligibility requirements.
2. A beneficiary is comparing several Part D statements involving Quantity limits. Which statement should
be selected as the accurate one?
A. It is a premium surcharge
B. It bans generics
C. It restricts the number of doctors a person may see
D. A quantity limit restricts the amount of a drug the plan will cover over a specified period unless an exception is
approved
Correct Answer: D. A quantity limit restricts the amount of a drug the plan will cover over a specified period
unless an exception is approved
Rationale: Quantity limits are formulary controls on the covered amount or frequency of a
medication.
3. Martha is reviewing Medicare coverage during a one-on-one appointment and asks about Covered
insulin cost sharing. Which statement is most accurate?
A. For 2026, covered insulin cost sharing for a month supply is capped at the lesser of $35, 25% of the maximum
fair price when applicable, or 25% of the plan negotiated price
B. No federal insulin rule applies to Part D
C. Always exactly $100
D. Insulin is excluded from Part D
Correct Answer: A. For 2026, covered insulin cost sharing for a month supply is capped at the lesser of $35,
25% of the maximum fair price when applicable, or 25% of the plan negotiated price
Rationale: The IRA limits beneficiary cost sharing for covered insulin products; in 2026 the cap uses the
lesser-of calculation specified by CMS.
4. A pharmacist and a beneficiary are trying to apply current 2026 Part D rules to Part D late enrollment
penalty. Which interpretation is correct?
A. The penalty applies only after 5 years
B. The trigger is 7 days
C. A person may owe a Part D late enrollment penalty after going 63 consecutive days or more without
Part D or other creditable drug coverage after becoming eligible, absent an exception
D. The penalty is a one-time $10 fee
Correct Answer: C. A person may owe a Part D late enrollment penalty after going 63 consecutive days or more
without Part D or other creditable drug coverage after becoming eligible, absent an exception
Rationale: The Part D late enrollment penalty can apply after a coverage gap of 63 consecutive days or more
without creditable prescription drug coverage.
5. Regarding ACIP vaccines, Which response best applies?
A. They are excluded from Part D
B. They always require 20% coinsurance
C. Part D-covered adult vaccines recommended by ACIP are available without enrollee cost sharing
D. Only flu vaccine can be covered
,Correct Answer: C. Part D-covered adult vaccines recommended by ACIP are available without enrollee cost
sharing
Rationale: The IRA eliminated cost sharing for recommended adult vaccines covered under Part D.
6. A beneficiary is comparing several Part D statements involving Part D eligibility. Which statement
should be selected as the accurate one?
A. A person generally may enroll in Part D if entitled to Part A or enrolled in Part B and residing in the plan
service area
B. Both Part A and Part B are always required
C. Medigap is required
D. Only MA enrollees may get Part D
Correct Answer: A. A person generally may enroll in Part D if entitled to Part A or enrolled in Part B and
residing in the plan service area
Rationale: Part D eligibility generally requires entitlement to Part A or enrollment in Part B, along with residence
and other applicable eligibility requirements.
7. Victor is reviewing Medicare coverage while reviewing Medicare choices with a licensed agent and asks
about Creditable drug coverage. Which action or explanation is most appropriate?
A. It means any discount card
B. It guarantees no premium
C. It is the same as Medigap
D. Creditable coverage is expected to pay, on average, at least as much as standard Medicare drug coverage and
can help a person avoid a Part D late penalty
Correct Answer: D. Creditable coverage is expected to pay, on average, at least as much as standard Medicare
drug coverage and can help a person avoid a Part D late penalty
Rationale: Creditable prescription coverage is important when deciding whether to delay Part D enrollment
because it affects late-enrollment penalty exposure.
8. A pharmacist and a beneficiary are trying to apply current 2026 Part D rules to Prior authorization.
Which interpretation is correct?
A. It is the same as a deductible
B. Prior authorization requires plan approval or specified criteria before coverage of certain prescriptions
C. It permanently removes the drug from the formulary
D. It means the drug is automatically free
Correct Answer: B. Prior authorization requires plan approval or specified criteria before coverage of certain
prescriptions
Rationale: Prior authorization is a utilization-management tool used to confirm coverage criteria before payment.
9. Regarding True out-of-pocket, Which statement best resolves the question?
A. TrOOP is the set of qualifying costs that count toward the beneficiary Part D annual out-of-pocket threshold
B. It includes the plan premium
C. It is the Part B deductible
D. It means total retail drug price only
Correct Answer: A. TrOOP is the set of qualifying costs that count toward the beneficiary
Part D annual out-of-pocket threshold
Rationale: TrOOP rules determine which beneficiary and qualifying third-party payments count toward the Part
D OOP threshold.
10. A beneficiary is comparing several Part D statements involving Formulary exception. Which statement
should be selected as the accurate one?
A. No exceptions are permitted under Part D
B. An enrollee or prescriber may request a formulary or tiering exception when applicable plan criteria are met
C. Exceptions automatically waive the premium
D. Only the pharmacy can appeal
Correct Answer: B. An enrollee or prescriber may request a formulary or tiering exception when applicable plan
criteria are met
Rationale: Part D provides a coverage-determination and exceptions process for nonformulary drugs and certain
utilization or tiering issues.
, 11. Thomas is reviewing Medicare coverage after moving to a new county and asks about Catastrophic cost
sharing. What should the beneficiary be told?
A. The enrollee pays 25%
B. The enrollee pays 5%
C. The deductible restarts
D. After reaching the 2026 Part D out-of-pocket threshold, the enrollee has no cost sharing for covered
Part D drugs for the rest of the year
Correct Answer: D. After reaching the 2026 Part D out-of-pocket threshold, the enrollee has no cost sharing for
covered Part D drugs for the rest of the year
Rationale: Under the redesigned Part D benefit, beneficiary cost sharing is $0 in the catastrophic phase.
12. A pharmacist and a beneficiary are trying to apply current 2026 Part D rules to Extra Help. Which
interpretation is correct?
A. It eliminates the need to enroll in drug coverage
B. It is a Part A hospital subsidy only
C. Extra Help reduces qualifying beneficiaries Part D premiums and prescription cost sharing
D. It is available regardless of income/resources with no criteria
Correct Answer: C. Extra Help reduces qualifying beneficiaries Part D premiums and prescription cost sharing
Rationale: The Low-Income Subsidy helps eligible beneficiaries with Part D costs.
13. Regarding Payment Plan effect, How should this situation be interpreted?
A. It substitutes for Extra Help
B. It increases the OOP cap
C. It converts all drug costs to zero
D. Using the Medicare Prescription Payment Plan does not reduce the total annual out-of-pocket amount owed for
covered drugs; it spreads payments over time
Correct Answer: D. Using the Medicare Prescription Payment Plan does not reduce the total annual
out-of-pocket amount owed for covered drugs; it spreads payments over time
Rationale: The program is a payment-smoothing mechanism, not an additional drug subsidy.
14. A beneficiary is comparing several Part D statements involving 2026 Part D deductible. Which
statement should be selected as the accurate one?
A. $2,100
B. $590
C. $615 is the maximum standard deductible for 2026
D. $283
Correct Answer: C. $615 is the maximum standard deductible for 2026
Rationale: CMS set the 2026 defined standard Part D deductible at $615.
15. Denise is reviewing Medicare coverage during a one-on-one appointment and asks about True
out-of-pocket. Which statement is most accurate?
A. It means total retail drug price only
B. TrOOP is the set of qualifying costs that count toward the beneficiary Part D annual out-of-pocket threshold
C. It includes the plan premium
D. It is the Part B deductible
Correct Answer: B. TrOOP is the set of qualifying costs that count toward the beneficiary
Part D annual out-of-pocket threshold
Rationale: TrOOP rules determine which beneficiary and qualifying third-party payments count toward the Part
D OOP threshold.
16. A pharmacist and a beneficiary are trying to apply current 2026 Part D rules to 2026 OOP threshold.
Which interpretation is correct?
A. $2,100 is the 2026 annual Part D out-of-pocket threshold
B. $8,300
C. $615
D. $2,000
Correct Answer: A. $2,100 is the 2026 annual Part D out-of-pocket threshold
