CEBS GBA 1 COMPREHENSIVE EXAM UPDATED QUESTIONS
AND ANSWERS GRADED A+
✔✔Common techniques to control pharmacy costs (Mod 6.3) - ✔✔1 = Review design of
benefits to see if they fit overall medical program (flat copays/no incr)
2 = Analyze experience to identify areas that need better management
3 = Reduce pharmacy network to smallest size w/o compromising access
4 = Offer mail service
5 = Promote generics
6 = Use/develop cost effective formulary
7 = Practice utilization management
8 = Physician profiling
9 = Educate and communicate to members the plan
10 = Anticipate financial impact of new drugs
✔✔What are 3 types of (DUR) drug utilization review programs? (Mod 6.3) -
✔✔Concurrent = Occurs at Point of Service (Pharmacy); flags overuse based on clinical
monitoring criteria programmed into PBM - too soon refills, duplicate claims
Retrospective = Pharmacy Case Management - pharmacists review patient profile to
determine compliance - can suggest alternative cost-effective therapies - therapeutic
switching
Prospective = Educating Physicians and patients on drugs/therapy
✔✔What is a Formulary? (Mod 6.3) - ✔✔List of preferred drugs by a health plan or
PBM. Developed by Pharmacy and Therapeutics Committee (P&T) to treat conditions
indigenous with insured population; designed to be cost effective - centers around
brand. Effective to move patients to lower cost drugs and maximum rebate potentials.
Drawback = constant communication b/w physicians and patients
✔✔Define Open, Closed and Preferred Formularies (Mod 6.3) - ✔✔Open = Allow plan
enrollees any covered prescription drug; most phys familiar with drugs they use most
often, gives best chance to make better informed choices. List of preferred drugs
distributed for informational use only.
Preferred = Popular; incentivizes use of preferred or formulary drugs in return for
reduced copay.
Closed = plan does not cover non-formulary drugs (met with resistance from EE's);
typically found in hospital settings and tightly managed HMOs - ERs do not use this
type.
✔✔Describe two main types of DSM programs (disease state management) and their
criticisms (Mod 6.4) - ✔✔Medical Model = Call Centers staffed by nurses to triage
patients to appropriate levels of care
,Therapy Directed Model = Administered by PBMs, pharm manuf, health plans and
disease management co's - improve compliance with medication therapy, education and
testing
-Critics say neither model has method to judge success and ROI - argue thinly veiled
advertisements from drug manufacturers.
Also say targeted diseases are easy to improve
✔✔What is (EBM) evidence based medicine? (Mod 6.4) - ✔✔Approach to medical
decision making that emphasizes scientific evidence and statistical methods for
evaluating outcomes/risk of treatments.
Response to arrive at objective decisions in the face of advertising/promotions to drugs.
✔✔How does a network system in a PDP operate? (Mod 6.4) - ✔✔EEs must fill at
network pharmacies. In an emergency, some plan sponsors will pay outside of network
but may require reimbursement for resulting cost in network.
Pharmacies join networks and provide discounts based on increased volume. PBM
designs networks.
✔✔What is a PBM? (Mod 6.5) - ✔✔Pharmacy Benefit Management
-Entity that administers managed pharm programs
-Streamlines/improves process of prescribing/dispensing through online/real time claims
adjudication
-Maintain network of pharm/mail order options to reduce cost/offer discounts/track
experience
-Offering limited DUR online at point of sale
-Providing data and reporting
-Controlling cost of prescriptions (formulary)
✔✔Methodology for PBM Prices (Mod 6.4) - ✔✔Prices can vary based on region, age,
industry, size, etc...
Ex:
Retail brand network = 12-16% off AWP, plus $1-3 dispensing fee
Retail generic network = MAC plus $0-3 fee
Mail order brand = 20-25% off AWP plus $0-1 fee
Mail order generic = 50-65% off AWP or MAC plus a $0-1 fee
✔✔How does a PBM generate profits? (Mod 6.4) - ✔✔Typical stream through claim
admin fees, mail service and rebates:
-Admin fee based on # of EE's or claims
-Rebate admin fees w/manufacturers
-Filling mail order from owned pharmacies
-Disease management, education
-Securing discounts through pharm network
-Retaining pharmacy spread
, -Retaining spread in MAC payments for generics greater than paid to pharm
-Reducing payments to pharm based on size
✔✔How does a drug rebate work? (Mod 6.4) - ✔✔Agreement between PBM and drug
manufacturer to secure significant reductions in cost of prescription drugs. Some
savings can be passed to Employer.
Over years, have grown from 1-2% to 6-9% of total. Growth has paralleled rise of
benefit inflation.
✔✔Describe the conditions to review before selecting PBM (Mod 6.4) - ✔✔-
Options/Pricing?
-Own Mail Order Program?
-Price Guarantees backed by Audit?
-Service/PGs?
-Reporting?
-DUR Edits? Routinely?
-Work with Physicians?
-Educational Programs?
-Disease Management?
-Ancillary Services?
-Preferred Drug List? Changes?
✔✔Define most severe mental illnesses (Mod 7.1) - ✔✔Schizophrenia, Bipolar, Major
Depressive Disorder - biologically based
✔✔List the categories of mental disorders (Mod 7.1) - ✔✔-Adjustment (Situational
Stress)
-Anxiety (Panic)
-Childhood (Autism)
-Eating (Anorexia)
-Mood (Major Depression)
-Cognitive (Dementia)
-Personality (Antisocial)
-Psychotic (Schizophrenia)
-Substance Related (Alcohol/Drug)
✔✔After WWII, why did insurers place limits on outpatient medical care? (Mod 7.1) -
✔✔Treatment continued for indefinite periods of time, much subjectivity regarding
treatment.
✔✔What were typical MH benefits of Health Maintenance Organizations like in the
1980s? (Mod 7.1) - ✔✔Extremely limited & differed from non-mental health coverage.
Hospital coverage restricted to 30-45 days per mental illness or 30-60/yr. For medical
illness, coverage unlimited.
AND ANSWERS GRADED A+
✔✔Common techniques to control pharmacy costs (Mod 6.3) - ✔✔1 = Review design of
benefits to see if they fit overall medical program (flat copays/no incr)
2 = Analyze experience to identify areas that need better management
3 = Reduce pharmacy network to smallest size w/o compromising access
4 = Offer mail service
5 = Promote generics
6 = Use/develop cost effective formulary
7 = Practice utilization management
8 = Physician profiling
9 = Educate and communicate to members the plan
10 = Anticipate financial impact of new drugs
✔✔What are 3 types of (DUR) drug utilization review programs? (Mod 6.3) -
✔✔Concurrent = Occurs at Point of Service (Pharmacy); flags overuse based on clinical
monitoring criteria programmed into PBM - too soon refills, duplicate claims
Retrospective = Pharmacy Case Management - pharmacists review patient profile to
determine compliance - can suggest alternative cost-effective therapies - therapeutic
switching
Prospective = Educating Physicians and patients on drugs/therapy
✔✔What is a Formulary? (Mod 6.3) - ✔✔List of preferred drugs by a health plan or
PBM. Developed by Pharmacy and Therapeutics Committee (P&T) to treat conditions
indigenous with insured population; designed to be cost effective - centers around
brand. Effective to move patients to lower cost drugs and maximum rebate potentials.
Drawback = constant communication b/w physicians and patients
✔✔Define Open, Closed and Preferred Formularies (Mod 6.3) - ✔✔Open = Allow plan
enrollees any covered prescription drug; most phys familiar with drugs they use most
often, gives best chance to make better informed choices. List of preferred drugs
distributed for informational use only.
Preferred = Popular; incentivizes use of preferred or formulary drugs in return for
reduced copay.
Closed = plan does not cover non-formulary drugs (met with resistance from EE's);
typically found in hospital settings and tightly managed HMOs - ERs do not use this
type.
✔✔Describe two main types of DSM programs (disease state management) and their
criticisms (Mod 6.4) - ✔✔Medical Model = Call Centers staffed by nurses to triage
patients to appropriate levels of care
,Therapy Directed Model = Administered by PBMs, pharm manuf, health plans and
disease management co's - improve compliance with medication therapy, education and
testing
-Critics say neither model has method to judge success and ROI - argue thinly veiled
advertisements from drug manufacturers.
Also say targeted diseases are easy to improve
✔✔What is (EBM) evidence based medicine? (Mod 6.4) - ✔✔Approach to medical
decision making that emphasizes scientific evidence and statistical methods for
evaluating outcomes/risk of treatments.
Response to arrive at objective decisions in the face of advertising/promotions to drugs.
✔✔How does a network system in a PDP operate? (Mod 6.4) - ✔✔EEs must fill at
network pharmacies. In an emergency, some plan sponsors will pay outside of network
but may require reimbursement for resulting cost in network.
Pharmacies join networks and provide discounts based on increased volume. PBM
designs networks.
✔✔What is a PBM? (Mod 6.5) - ✔✔Pharmacy Benefit Management
-Entity that administers managed pharm programs
-Streamlines/improves process of prescribing/dispensing through online/real time claims
adjudication
-Maintain network of pharm/mail order options to reduce cost/offer discounts/track
experience
-Offering limited DUR online at point of sale
-Providing data and reporting
-Controlling cost of prescriptions (formulary)
✔✔Methodology for PBM Prices (Mod 6.4) - ✔✔Prices can vary based on region, age,
industry, size, etc...
Ex:
Retail brand network = 12-16% off AWP, plus $1-3 dispensing fee
Retail generic network = MAC plus $0-3 fee
Mail order brand = 20-25% off AWP plus $0-1 fee
Mail order generic = 50-65% off AWP or MAC plus a $0-1 fee
✔✔How does a PBM generate profits? (Mod 6.4) - ✔✔Typical stream through claim
admin fees, mail service and rebates:
-Admin fee based on # of EE's or claims
-Rebate admin fees w/manufacturers
-Filling mail order from owned pharmacies
-Disease management, education
-Securing discounts through pharm network
-Retaining pharmacy spread
, -Retaining spread in MAC payments for generics greater than paid to pharm
-Reducing payments to pharm based on size
✔✔How does a drug rebate work? (Mod 6.4) - ✔✔Agreement between PBM and drug
manufacturer to secure significant reductions in cost of prescription drugs. Some
savings can be passed to Employer.
Over years, have grown from 1-2% to 6-9% of total. Growth has paralleled rise of
benefit inflation.
✔✔Describe the conditions to review before selecting PBM (Mod 6.4) - ✔✔-
Options/Pricing?
-Own Mail Order Program?
-Price Guarantees backed by Audit?
-Service/PGs?
-Reporting?
-DUR Edits? Routinely?
-Work with Physicians?
-Educational Programs?
-Disease Management?
-Ancillary Services?
-Preferred Drug List? Changes?
✔✔Define most severe mental illnesses (Mod 7.1) - ✔✔Schizophrenia, Bipolar, Major
Depressive Disorder - biologically based
✔✔List the categories of mental disorders (Mod 7.1) - ✔✔-Adjustment (Situational
Stress)
-Anxiety (Panic)
-Childhood (Autism)
-Eating (Anorexia)
-Mood (Major Depression)
-Cognitive (Dementia)
-Personality (Antisocial)
-Psychotic (Schizophrenia)
-Substance Related (Alcohol/Drug)
✔✔After WWII, why did insurers place limits on outpatient medical care? (Mod 7.1) -
✔✔Treatment continued for indefinite periods of time, much subjectivity regarding
treatment.
✔✔What were typical MH benefits of Health Maintenance Organizations like in the
1980s? (Mod 7.1) - ✔✔Extremely limited & differed from non-mental health coverage.
Hospital coverage restricted to 30-45 days per mental illness or 30-60/yr. For medical
illness, coverage unlimited.
