The Hall Health Plan gathered objective clinical information about the recommended uses and dosages of angiotensin-converting enzyme (ACE) inhibitors and presented the information to network providers to illustrate the appropriate use of these frequently prescribed and expensive drugs. This information indicates that Hall most likely educated its network providers through the use of

1. A. detailing
2. B. cognitive services
3. C. counter detailing
4. D. drug efficacy study implementation (DESI)

Correct Answer: C

The Garnet Health Plan uses provider profiling to measure and improve provider performance. Provider profiling most likely allows Garnet to

1. A. evaluate all providers without considering differences in risk
2. B. focus on specific clinical decisions of Garnet’s providers rather than on patterns of care
3. C. identify the outliers and high-value providers in its provider network
4. D. measure the effectiveness, but not the efficiency, of Garnet’s providers

Correct Answer: C

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.
The paragraph below contains two pairs of terms enclosed in parentheses. Determine which term in each pair correctly completes the paragraph. Then select the answer choice containing the two terms that you have chosen.
Greenhouse’s prescription drug reimbursement policy indicates that the plan formulary is classified as (open / closed), and that compliance by patients and providers is (mandatory / voluntary).

1. A. open / mandatory
2. B. open / voluntary
3. C. closed / mandatory
4. D. closed / voluntary

Correct Answer: C

Among this agency’s accreditation programs are accreditation for preferred provider organizations (PPOs), health plan call centers, and case management organizations. This agency classifies its standards as either “shall” standards or “should” standards.

1. A. American Accreditation HealthCare Commission/URAC (URAC)
2. B. Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
3. C. Community Health Accreditation Program (CHAP)
4. D. National Committee for Quality Assurance (NCQA)

Correct Answer: A

All states have laws describing the conditions under which pharmacists can substitute a generic drug for a brand-name drug. With respect to these laws, it is correct to say that in every state,

1. A. pharmacists must obtain physician approval before substituting generics for brand-name drugs
2. B. pharmacists must obtain authorization from the health plan before substituting generics for brand-name drugs
3. C. prescribers must obtain authorization from the health plan before prescribing a brand- name drug
4. D. prescribers have some mechanism that allows them to prevent pharmacists from substituting generics for brand-name drugs

Correct Answer: D