AHIP AHM-540 問題集

質問 1：
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).
A. closed / mandatory
B. open / voluntary
C. open / mandatory
D. closed / voluntary
正解：A

質問 2：
The Glenway Health Plan's pharmacy and therapeutics (P&T) committee conducted pharmacoeconomic research to measure both the clinical outcomes and costs of two new cholesterol-reducing drugs. Results were presented as a ratio showing the cost required to produce a 1 mcg/l decrease in cholesterol levels. The type of pharmacoeconomic research that Glenway conducted in this situation was most likely
A. cost-minimization analysis (CMA)
B. cost-utility analysis (CUA)
C. cost-effectiveness analysis (CEA)
D. cost of illness analysis (COI)
正解：C

質問 3：
Helena Ray, a member of the Harbrace Health Plan, suffers from migraine headaches. To treat Ms. Ray's condition, her physician has prescribed Upzil, a medication that has Food and Drug Administration (FDA) approval only for the treatment of depression. Upzil has not been tested for safety or effectiveness in the treatment of migraine headache. Although Harbrace's medical policy for migraine headache does not include coverage of Upzil, Harbrace has agreed to provide extra-contractual coverage of Upzil for Ms. Ray.
The following statement(s) can correctly be made about Harbrace's use of extra-contractual coverage: 1.Harbrace's medical policy most likely establishes the procedure that Harbrace used to evaluate the value of Upzil for treating Ms. Ray
2.One way for Harbrace to reduce the risk associated with extra-contractual coverage is by including an alternative care provision in its contracts with purchasers
A. Neither 1 nor 2
B. 2 only
C. Both 1 and 2
D. 1 only
正解：B

質問 4：
One way that health plans can make their benefits more appealing to employers and employees is to offer coverage for specialty services. It is correct to say that specialty services typically
A. involve the same types of providers and delivery systems as do standard medical services
B. are not monitored by health plans for quality or utilization
C. are a subset of a health plan's standard medical-surgical services
D. require specialized knowledge for service delivery and management
正解：D

質問 5：
Since its inception, Medicare has undergone a number of changes because of legal and regulatory action. One result of the Balanced Budget Act (BBA) of 1997 has been to
A. expand Medicare benefits by mandating coverage for certain preventive services
B. reduce the number of organizations that can deliver covered services
C. encourage growth of managed Medicare programs in all markets
D. increase the number of "zero premium" plans available to Medicare beneficiaries
正解：A

質問 6：
Health plans that offer complementary and alternative medicine (CAM) services face potential liability because many types of CAM services
A. lack clinical trials to evaluate their safety and effectiveness
B. focus on a specific illness, injury, or symptom rather than on the whole body
C. must be offered as separate supplemental benefits or separate products
D. are not covered by state or federal consumer protection statutes
正解：A