AHIP Final Exam (Latest 2024/2025) | Passed | A+ Rated Guide | New Full Exam
AHIP Final Exam (Latest 2024/2025) | Passed
| A+ Rated Guide | New Full
... [Show More] Exam
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?
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?
The POS option might be a good solution for him as it will allow him to visit outof-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 outof-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 MAPD 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?
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?
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.
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?
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?
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? [Show Less]