PTCB - PHARMACY BILLING AND
REIMBURSEMENT QUESTIONS AND
ANSWERS WITH VERIFIED SOLUTIONS
|UPDATED 2025|
1. Medicare Advantage (Medicare Part C)
Answer: Allows participants in Medicare Part A and B to obtain coverage
through a Health Maintenance Organization or Preferred Provider
Organization that provides additional services at a higher cost.
2. Medicare Part A
Answer: A federally funded health care program that pays for a patient's
inpatient hospital care, skilled nursing care, hospice care, and home health
care.
3. Medicare Part B
Answer: A federally funded health care program that provides a patient with
coverage for physician visits, outpatient care, physical therapy, and
occupational therapy.
4. Medicare Part D
Answer: A federally funded health care program that provides a patient with
coverage for select prescription medications, medical supplies, insulin, and
vaccinations.
5. Medicaid
Answer: A federal program based on income as well as other circumstances.
Eligibility is determined on a month-by-month basis. It generally covers
, doctor's visits, emergency care, hospital care, vaccinations, prescriptions,
vision, hearing, and preventative care for children.
6. Average Wholesale Price
Answer: The average price that wholesalers sell a medication.
7. Actual Acquisition Cost
Answer: The actual cost a pharmacy paid for a medication.
8. Formulary
Answer: A list of medications approved for use or reimbursement under a
prescription plan.
9. Open Formulary
Answer: A variety of several medications in each therapeutic classification.
10. Closed Formulary
Answer: A very limited number of medications available in each therapeutic
classification, and sometimes no medications in certain classifications.
11. Restricted Formulary
Answer: A selective, limited, partially closed formulary in which some non-
formulary medications are available.
12. Online Adjudication
Answer: The process by which a pharmacy submits prescription claims
electronically to a third-party provider to ensure accurate copayments and
REIMBURSEMENT QUESTIONS AND
ANSWERS WITH VERIFIED SOLUTIONS
|UPDATED 2025|
1. Medicare Advantage (Medicare Part C)
Answer: Allows participants in Medicare Part A and B to obtain coverage
through a Health Maintenance Organization or Preferred Provider
Organization that provides additional services at a higher cost.
2. Medicare Part A
Answer: A federally funded health care program that pays for a patient's
inpatient hospital care, skilled nursing care, hospice care, and home health
care.
3. Medicare Part B
Answer: A federally funded health care program that provides a patient with
coverage for physician visits, outpatient care, physical therapy, and
occupational therapy.
4. Medicare Part D
Answer: A federally funded health care program that provides a patient with
coverage for select prescription medications, medical supplies, insulin, and
vaccinations.
5. Medicaid
Answer: A federal program based on income as well as other circumstances.
Eligibility is determined on a month-by-month basis. It generally covers
, doctor's visits, emergency care, hospital care, vaccinations, prescriptions,
vision, hearing, and preventative care for children.
6. Average Wholesale Price
Answer: The average price that wholesalers sell a medication.
7. Actual Acquisition Cost
Answer: The actual cost a pharmacy paid for a medication.
8. Formulary
Answer: A list of medications approved for use or reimbursement under a
prescription plan.
9. Open Formulary
Answer: A variety of several medications in each therapeutic classification.
10. Closed Formulary
Answer: A very limited number of medications available in each therapeutic
classification, and sometimes no medications in certain classifications.
11. Restricted Formulary
Answer: A selective, limited, partially closed formulary in which some non-
formulary medications are available.
12. Online Adjudication
Answer: The process by which a pharmacy submits prescription claims
electronically to a third-party provider to ensure accurate copayments and
