AHIP - FINAL EXAMINATION (LATEST 2025-2026)
50+ COMPLETE QUESTIONS AND CORRECT
DETAILED ANSWERS / 2025-2026
Terms in this set (50)
Mr. Zachow has a condition Mr. Zachow has a right to request a formulary exception to
for which three drugs are obtain coverage for his Part D drug. He or his physician could
available. He has tried two obtain the standardized request form on the plan's website,
but had an allergic reaction fill it out, and submit it to his plan.
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
Mr. Polanski likes the cost of prior approval. However, he should be aware that it is likely
an HMO plan available in his he will have to pay higher cost-sharing for services from out-
area, but would like to be able of-network providers.
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?
Mr. Barker had surgery You can offer to review the plans appeal process to help him
recently and expected that ask the plan to review the coverage decision.
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 Dcoverage for
prescription drugs.
Ms. Stuart has heard about a
special needs plan (SNP) that b. Yes, but only if she qualifies for Part D prescriptiondrug
one of her friends is enrolled coverage under her state Medicaid program.
in and is interested in that c. No. Medicare beneficiaries who enroll in an SNPmust always
product. She wants to be
obtain their drug coverage through a stand-alone Part D
sure she also has coverage
for prescription drugs. Would Medicare prescription drug plan that they sign up for
she be able to obtain drug independent of their enrollment in the SNP.
coverage if she enrolled in d. Maybe. Some SNPs offer Part D coverage forprescription
the SNP?
drugs and some do not.
= ?????
Phiona works in the IT II. All data elements required to complete anenrollment
Department of BestCare request must be captured.
Health Plan. Phiona is placed III. The process must include a clear and distinct
in charge of BestCare's efforts stepthat requires the applicant to activate an "Enroll Now" or
to facilitate electronic "I Agree" type of button or tool.
enrollment in its Medicare
Advantage plans. In setting
up the enrollment site, which
of the following must Phiona
consider?
Ms. Lewis understands that Step therapy involves using one or more lower priced drugs
Medicare prescription drug before trying a more expensive drug when all are used to
plans may use various treat the same condition.
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?
50+ COMPLETE QUESTIONS AND CORRECT
DETAILED ANSWERS / 2025-2026
Terms in this set (50)
Mr. Zachow has a condition Mr. Zachow has a right to request a formulary exception to
for which three drugs are obtain coverage for his Part D drug. He or his physician could
available. He has tried two obtain the standardized request form on the plan's website,
but had an allergic reaction fill it out, and submit it to his plan.
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
Mr. Polanski likes the cost of prior approval. However, he should be aware that it is likely
an HMO plan available in his he will have to pay higher cost-sharing for services from out-
area, but would like to be able of-network providers.
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?
Mr. Barker had surgery You can offer to review the plans appeal process to help him
recently and expected that ask the plan to review the coverage decision.
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 Dcoverage for
prescription drugs.
Ms. Stuart has heard about a
special needs plan (SNP) that b. Yes, but only if she qualifies for Part D prescriptiondrug
one of her friends is enrolled coverage under her state Medicaid program.
in and is interested in that c. No. Medicare beneficiaries who enroll in an SNPmust always
product. She wants to be
obtain their drug coverage through a stand-alone Part D
sure she also has coverage
for prescription drugs. Would Medicare prescription drug plan that they sign up for
she be able to obtain drug independent of their enrollment in the SNP.
coverage if she enrolled in d. Maybe. Some SNPs offer Part D coverage forprescription
the SNP?
drugs and some do not.
= ?????
Phiona works in the IT II. All data elements required to complete anenrollment
Department of BestCare request must be captured.
Health Plan. Phiona is placed III. The process must include a clear and distinct
in charge of BestCare's efforts stepthat requires the applicant to activate an "Enroll Now" or
to facilitate electronic "I Agree" type of button or tool.
enrollment in its Medicare
Advantage plans. In setting
up the enrollment site, which
of the following must Phiona
consider?
Ms. Lewis understands that Step therapy involves using one or more lower priced drugs
Medicare prescription drug before trying a more expensive drug when all are used to
plans may use various treat the same condition.
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?
