lOMoARcPSD|26582732
AHIP - Final Examination 2025-2026
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? - ANS 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. 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? - ANS 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. 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? - ANS You Can
Offer To Review The Plans Appeal Process To Help Him Ask The Plan To Review The
Coverage Decision.
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? - ANS 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.
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.
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d. Maybe. Some Snps Offer Part D Coverage For Prescription Drugs And Some Do
Not.
= ?????
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? - ANS 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.
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? ANS 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.
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? - ANS 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. Wu Is Eligible For Medicare. He Has Limited Financial Resources But Failed To
Qualify For The Part D Low-Income Subsidy. Where Might He Turn For Help With His
Prescription Drug Costs? - ANS Mr. Wu May Still Qualify For Help In Paying Part D
Costs Through His State Pharmaceutical Assistance Program.
You Have Decided To Focus On Doing In-Home Presentations To Market The Medicare
Advantage (MA) Plans You Represent. Before You Conduct Such Sales Presentations,
What Must You Do? - ANS
Mr. Wong Is A Single Individual. He Has Had A Successful Business Career And Is
Now Able To Retire With A Comfortable Income. Mr. Wong's Taxable Income Is In
Excess Of $100,000. Mr. Wong Has Health Coverage Through His Employer But Will
Sign-Up Medicare Part A, Part B And Part D When He Leaves The Workforce. How
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AHIP - Final Examination 2025-2026
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? - ANS 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. 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? - ANS 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. 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? - ANS You Can
Offer To Review The Plans Appeal Process To Help Him Ask The Plan To Review The
Coverage Decision.
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? - ANS 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.
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.
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d. Maybe. Some Snps Offer Part D Coverage For Prescription Drugs And Some Do
Not.
= ?????
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? - ANS 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.
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? ANS 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.
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? - ANS 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. Wu Is Eligible For Medicare. He Has Limited Financial Resources But Failed To
Qualify For The Part D Low-Income Subsidy. Where Might He Turn For Help With His
Prescription Drug Costs? - ANS Mr. Wu May Still Qualify For Help In Paying Part D
Costs Through His State Pharmaceutical Assistance Program.
You Have Decided To Focus On Doing In-Home Presentations To Market The Medicare
Advantage (MA) Plans You Represent. Before You Conduct Such Sales Presentations,
What Must You Do? - ANS
Mr. Wong Is A Single Individual. He Has Had A Successful Business Career And Is
Now Able To Retire With A Comfortable Income. Mr. Wong's Taxable Income Is In
Excess Of $100,000. Mr. Wong Has Health Coverage Through His Employer But Will
Sign-Up Medicare Part A, Part B And Part D When He Leaves The Workforce. How
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