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Health plans that choose to contract with external organizations for pharmacy services typically

contract with pharmacy benefit managers (PBMs). Functions that a PBM typically performs for a

health plan include

1. Managing the costs of prescription drugs

2. Promoting efficient and safe drug use

3. Determining the health plan’s internal management responsibilities for pharmacy services

The paragraph below contains two pairs of terms 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.

Health plans use both internal and external standards to assess the quality of the services that

they provide. (Internal / External) standards are based on information such as published industrywide

averages or best practices of recognized industry leaders. Health plans primarily rely on

(internal / external) standards to evaluate healthcare services. 

The following statement(s) can correctly be made about the scope of case management:

1. Case management incorporates activities that may fall outside a health plan’s typical

responsibilities, such as assessing a member’s financial situation

2. Case management generally requires a less comprehensive and complex approach to a course

of care than does utilization review

3. Case management is currently applicable only to medical conditions that require inpatient

hospital care and are categorized as catastrophic in terms of health and/or costs 

A health plan’s coverage policies are linked to its purchaser contracts. The following statement(s) can correctly be made about the purchaser contract and coverage decisions: 1. In case of conflict between the purchaser contract and a health plan’s medical policy or benefits administration policy, the contract takes precedence 2. Purchaser contracts commonly exclude custodial care from their coverage of services and supplies 3. All of the criteria for coverage decisions must be included in the purchaser contract  

One true statement about state regulation of case management activities is that the majority of states