Adele Stanley, a member of the Greenhouse Health Plan, recently went to a network pharmacy to have a prescription filled. The pharmacist informed Ms. Stanley that the prescribed drug was not in the plan formulary and that reimbursement for the drug was not available except in extraordinary circumstances. The pharmacist asked Ms. Stanley if she would accept a generic substitute.
If Ms. Stanley agrees to the generic substitution, she will receive a drug that
has not been tested for safety and efficacy in large clinical trials
is available without a prescription at a reasonable cost
has been classified by the Food and Drug Administration (FDA) as safe, but that has not been proven fully effective
contains active ingredients that are identical to those of the prescribed brand-name drug
Correct answer: D
A health plans coverage policies are linked to its purchaser contracts. The following
statement(s) can correctly be made about the purchaser contract and coverage decisions:
In case of conflict between the purchaser contract and a health plans medical policy or benefits administration policy, the contract takes precedence
Purchaser contracts commonly exclude custodial care from their coverage of services and supplies
All of the criteria for coverage decisions must be included in the purchaser contract
All of the above
1 and 2 only
Correct answer: B
Most health plans require a PCP referral or precertification for CAM benefits.