Quiz
Alberta Blue Cross 2018
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Questions in this quiz (34)
1 Government Sponsored Drug Plans
– [blank_start]Population Health[blank_end]- APopulation Health
2[blank_start]Employer Sponsored Group[blank_end] Plans
– Keeping people at work
– Recruitment and Retention strategy- AEmployer Sponsored Group
3Individual Plans
– Protection from [blank_start]unexpected health costs[blank_end]- Aunexpected health costs
4The Drug Review Process:
•Manufacturer → [blank_start]New drug submission[blank_end] → •Health Canada → Grants [blank_start]Notice of Compliance[blank_end] → •Manufacturer → [blank_start]Comprehensive review[blank_end] → •Payers- ANew drug submission
- BNotice of Compliance
- CComprehensive review
5Alberta Blue Cross Pharmaceutical Services Provider Agreement involves:
[blank_start]RxA[blank_end], [blank_start]AH[blank_end], and [blank_start]ABC[blank_end]- ARxA
- BAH
- CABC
6Manufacturer's List Price (MLP)
Published drug price is the [blank_start]Alberta Drug Benefit List (ADBL)[blank_end]
- Price is established by AH through the [blank_start]Alberta Price Confirmation[blank_end] policy
- Manufacturers agree to supply the drug into the Alberta market place
- [blank_start]Maximum price[blank_end] that can be charged to ABC plan members- AADBL
- BAlberta Price Confirmation
- CMaximum price
7Pricing Based on: Manufacturer List Price (MLP) or LCA
Drug Price MLP or LCA
Upcharge #1 [blank_start]3%[blank_end] (of MLP or LCA)
Upcharge #2 [blank_start]7%[blank_end] up to $100.00
(based on drug price +upcharge #1)
Dispensing Fee $[blank_start]12.30[blank_end]- A3%
- B7%
- C12.30
8Base Price (BP)
Price established by Alberta Blue Cross for all drugs that are:
– not listed on the [blank_start]Alberta Drug Benefit List[blank_end], and
– defined or listed within the [blank_start]Alberta Blue Cross Drug Price List[blank_end]
- Maximum price that can be charged to ABC plan members- AADBL
- BABCDPL
9Pricing Based on: Base Price (BP)
Drug Price BP (found on the ABCDPL)
Upcharge #1 = [blank_start]7.5%[blank_end]
Upcharge #2 (Based on Drug Price + Upcharge #1) = [blank_start]7%[blank_end] up to $100.00
Dispensing Fee = $[blank_start]12.30[blank_end]- A7.5%
- B7%
- C12.30
10Pricing based on other insurer:
Upcharge #1 = [blank_start]7.8%[blank_end]
Upcharge #2 = [blank_start]7.8%[blank_end]
Dispensing fee = $[blank_start]15.00[blank_end]- A7.8%
- B7.8%
- C15.00
11Pricing based on: Cash Paying Patient
Upcharge #1 = [blank_start]15%[blank_end]
Upcharge #2 = [blank_start]15%[blank_end]
Dispensing fee = $[blank_start]15.00[blank_end]- A15.00
- B15%
- C15%
12Coverage for Seniors
• When an [blank_start]Alberta resident[blank_end] reaches [blank_start]65[blank_end] years of age, the resident and all eligible dependants automatically qualify
• Seniors must register providing proof of age- AAlberta resident
- B65
13Non-Group Coverage
• The Government of Alberta offers Non-Group Coverage to ensure all [blank_start]Albertans[blank_end] have access to an economical supplementary health benefits program
• A [blank_start]monthly premium[blank_end] is charged for Non-Group coverage- AAlbertans
- Bmonthly premium
14Non-Group Coverage
• Coverage that a person can choose to purchase
• [blank_start]Drug only[blank_end]
• [blank_start]ADBL drugs[blank_end]
• [blank_start]Covers existing conditions[blank_end]
• [blank_start]Government sponsored[blank_end]- ADrug only
- BDrug, dental, travel, etc.
- CADBL drugs
- DMore drugs than the ADBL
- ECovers existing conditions
- FExcludes existing conditions
- GGovernment sponsored
- HSelf-funded
15ABC Individual Coverage
• Coverage that a person can choose to purchase
• [blank_start]Drug, dental, travel, etc.[blank_end]
• [blank_start]More drugs than the ADBL[blank_end]
• [blank_start]Excludes existing conditions[blank_end]
• [blank_start]Self-funded[blank_end]- ADrug, dental, travel, etc.
- BDrug only
- CMore drugs than the ADBL
- DADBL drugs
- EExcludes existing conditions
- FCovers existing conditions
- GSelf-funded
- HGovernment sponsored
16 [blank_start]Income Support[blank_end] – financial and health benefits
- AIncome Support
17[blank_start]Barriers to Full Employment[blank_end] - people who cannot work due to
chronic health problems or other barriers to employment- ABarriers to Full Employment
18[blank_start]Expected to Work[blank_end] - People who are looking for work, working but
not earning enough, or temporarily unable to work- AExpected to Work
19[blank_start]Learners[blank_end] - People who need upgrading or training so they can get a
job- ALearners
20[blank_start]Alberta Adult Health Benefit[blank_end] – health benefits
– Supports Albertans in low income to ensure they have access to
prescription drugs- AAlberta Adult Health Benefit
21[blank_start]Alberta Child Health Benefit[blank_end] – health benefits
– Is for families with limited incomes. Benefits for children up to age
20 who live at home and are attending high school up to grade 12- AAlberta Child Health Benefit
22• Low Income plans
- [blank_start]No copay[blank_end]
• Coverage for Seniors and Non-group Coverage
- [blank_start]30%[blank_end] copay up to $[blank_start]25[blank_end] max per prescription- ANo copay
- B30%
- C25
23[blank_start]Alberta Drug Benefit Supplement (ADBS)[blank_end]
– Defines additional prescription drugs and drug products covered by Low Income Plans- AADBS
24[blank_start]Interactive Drug Benefit List (iDBL)[blank_end]
– Online version of the [blank_start]ADBL[blank_end] and [blank_start]ADBS[blank_end]
- Real time document, updated daily
– Great resource for:
• Checking if a product is an eligible benefit and when it
became effective
• Checking drug pricing and interchangeability
• Checking which product is the least cost alternative (LCA) or
Maximum Allowable Cost (MAC)
• Checking Special authorization coverage criteria- AADBL
- BADBS
- CiDBL
25[blank_start]Least Cost Alternative (LCA)[blank_end]
- The lowest cost medication in an interchangeable (generic) drug grouping.- ALCA
26[blank_start]Maximum Allowable Cost (MAC)[blank_end]
- The maximum amount these plans will pay for a specific drug product- AMAC
27[blank_start]Special Authorization[blank_end]
• A drug benefit management strategy that ensures select drugs are covered for those most likely to benefit.
• Special authorization request forms are completed by [blank_start]prescribers[blank_end].
• Coverage is considered based on criteria published in the [blank_start]ADBL[blank_end].- Aprescribers
- BADBL
- CSpecial Authorization
28[blank_start]Step Therapy[blank_end]
– For drugs which are 2nd or 3rd line
– Claims system looks for use of 1st line before paying
– Message back to pharmacy only in cases where the 1st line has not been claimed- AStep Therapy
29[blank_start]Restricted Benefit[blank_end]
– Restricted by quantity, age group, prescriber
– Claim system validates before paying
– Message back to pharmacy in cases where
restriction is not met- ARestricted Benefit
30>100 days supply (Snowbird)
• Available only for [blank_start]seniors[blank_end] or [blank_start]non-group[blank_end] members leaving the province for more than 100 days.
• One authorization per [blank_start]year[blank_end] (July 1 to June 30).
• Up to a maximum of [blank_start]200 day[blank_end]s’ supply considering quantities on hand.
• Plan members must be [blank_start]stabilized[blank_end] on their medication.
• Claims system will automatically determine the days supply allowed.- Aseniors
- Bnon-group
- Cyear
- D200 day
- Estabilized
31Coordination of Benefits (COB)
Principle #1- [blank_start]Cardholder[blank_end] pays first, spouse, or dependent pays second- ACardholder
32Coordination of Benefits (COB)
Principle #2 - If a dependant has coverage under 2 parents, the one with an earlier [blank_start]birthdate[blank_end] in the year pays first.- Abirthdate
33Coordination of Benefits (COB)
Principle #3 - Government plans can declare themselves as first payer ([blank_start]seniors[blank_end]), last payer ([blank_start]low income plans[blank_end]), or follow the general rules ([blank_start]non-group[blank_end])- Aseniors
- Blow income plans
- Cnon-group
34Coordination of Benefits (COB)
Principle #4 - The [blank_start]second[blank_end] plan will figure out how much it would have paid if it was primary, then pay that or the remaining amount, whichever is less- Asecond
Information
- Description
- – Overview of Alberta Blue Cross – Types of Drug Plans – Drug Approval and Formulary Development – Agreement and Pricing Introduction – ADBL/iDBL – Special Authorization
- Author
- Crystal Yu
- Language
- English
- Views
- 11
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