100+ Free PTCB Billing & Reimbursement Practice Questions

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Question 1

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Which entity administers prescription drug benefits on behalf of health plans and negotiates with pharmacies, manufacturers, and plan sponsors?

Pharmacy Benefit Manager (PBM)

Centers for Medicare and Medicaid Services (CMS)

Food and Drug Administration (FDA)

Drug Enforcement Administration (DEA)

to track

2026 Statistics

Key Facts: PTCB Billing & Reimbursement Exam

$89

Exam Fee

PTCB

Questions

PTCB (effective Jan 5, 2026)

1h 30m

Appointment Time

PTCB

300 / 400

Passing Score

PTCB

CPhT required

Prerequisite

PTCB

ABC

Credential Type

Assessment-Based Certificate

The PTCB Billing and Reimbursement Certificate is an Assessment-Based Certificate (ABC) — not a full credential like CPhT or CSPT — administered by the Pharmacy Technician Certification Board. Starting January 5, 2026, the exam contains 75 multiple-choice questions (expanded from 70) with a 1 hour 30 minute total appointment time and a scaled passing score of 300 out of 400. The fee is $89 and candidates must hold active PTCB CPhT certification plus meet an experience or training pathway. The exam covers Programs & Eligibility (26.67%), Pharmacy Claims Processing & Adjudication (36.67%), Medical Claims Processing & Adjudication (8.33%), Prior Authorization (18.33%), and Audits & Compliance (10%).

Sample PTCB Billing & Reimbursement Practice Questions

Try these sample questions to test your PTCB Billing & Reimbursement exam readiness. Each question includes a detailed explanation. Start the interactive quiz above for the full 100+ question experience with AI tutoring.

1Which entity administers prescription drug benefits on behalf of health plans and negotiates with pharmacies, manufacturers, and plan sponsors?

A.Pharmacy Benefit Manager (PBM)

B.Centers for Medicare and Medicaid Services (CMS)

C.Food and Drug Administration (FDA)

D.Drug Enforcement Administration (DEA)

Explanation: A Pharmacy Benefit Manager (PBM) such as CVS Caremark, Express Scripts, or OptumRx administers prescription drug benefits for insurers, employers, and government plans. PBMs build formularies, negotiate rebates with manufacturers, adjudicate pharmacy claims in real time, and reimburse pharmacies for dispensed medications.

2A Medicare beneficiary needs a nebulizer solution (albuterol unit-dose) to use at home with a nebulizer machine. Under which Medicare part is this typically billed?

A.Medicare Part B (as durable medical equipment supply)

B.Medicare Part A

C.Medicare Part D

D.Medicare Part C always

Explanation: Inhalation drugs used with a nebulizer at home are considered a supply used with durable medical equipment (DME) and are covered under Medicare Part B, not Part D. The same medication dispensed as a metered-dose inhaler would typically fall under Part D. Knowing the Part B vs Part D split is essential for pharmacy billing.

3What does the BIN field on a pharmacy insurance card identify in an NCPDP claim?

A.The processor or PBM that will adjudicate the claim

B.The patient's individual cardholder ID

C.The employer or plan group number

D.The prescribing physician's NPI

Explanation: The Bank Identification Number (BIN) routes a pharmacy claim to the correct processor or PBM. The Processor Control Number (PCN) further specifies the plan within that processor, and the Group Number identifies the employer or benefit plan. The Cardholder ID identifies the specific patient. BIN and PCN together determine where the claim is sent.

4NCPDP reject code 79 indicates what issue?

A.Refill Too Soon

B.Prior Authorization Required

C.Product/Service Not Covered

D.Missing/Invalid Prescriber ID

Explanation: Reject code 79 is 'Refill Too Soon,' meaning the patient is attempting to refill before the plan's required percentage of days' supply has elapsed (often 75 to 80 percent). Most plans use the last fill date plus days supply to calculate when the next fill is allowed. Common remedies include waiting a few days or requesting a vacation override from the PBM.

5NCPDP reject code 70 indicates what issue?

A.Product/Service Not Covered

B.Refill Too Soon

C.Non-Matched Cardholder ID

D.Missing/Invalid Days Supply

Explanation: Reject code 70 means the product or service is not covered by the plan. Common causes include non-formulary drugs, lifestyle drugs excluded from the benefit, medications covered under a different benefit (e.g., Part B rather than Part D), or plan carve-outs. The tech's next step is typically to request a formulary alternative or start a formulary exception.

6NCPDP reject code 75 indicates what issue?

A.Prior Authorization Required

B.Plan Limitations Exceeded

C.DUR Reject Error

D.Refill Too Soon

Explanation: Reject code 75 indicates that prior authorization is required from the plan before the medication will be covered. The technician should notify the prescriber so the prescriber can initiate a PA request with the plan. Many PBMs use electronic PA portals (e.g., CoverMyMeds) to speed resolution.

7NCPDP reject code 76 indicates what issue?

A.Plan Limitations Exceeded

B.Product/Service Not Covered

C.Refill Too Soon

D.Prior Authorization Required

Explanation: Reject code 76 means the plan's limitations have been exceeded — most commonly a quantity limit (e.g., 9 sumatriptan tablets per 30 days) or a dollar maximum. The technician may need to request a quantity limit exception or have the prescriber reduce the quantity to the plan's allowed amount.

8A claim rejects with code 88 (DUR Reject Error) and an additional reason code of TD (Therapeutic Duplication). What is the most appropriate first step?

A.Review the patient's profile for a similar therapeutic agent and contact the prescriber if clinically necessary

B.Immediately override the reject with a '1G' intervention code without documentation

C.Submit the claim as cash and bill the patient in full

D.Tell the patient the drug is no longer covered

Explanation: A DUR (Drug Utilization Review) reject with TD (Therapeutic Duplication) alerts that another drug in the same therapeutic class is on the profile. The tech must review the history and consult the pharmacist and prescriber before deciding to override. Overrides use DUR fields (reason for service, professional service code, and result of service code) and must be clinically justified.

9A patient brings a prescription for brand-name Synthroid, but the prescriber has not authorized a generic substitution. Which DAW code is submitted on the claim?

A.DAW 1 — Substitution Not Allowed by Prescriber

B.DAW 0 — No Product Selection Indicated

C.DAW 2 — Substitution Allowed, Patient Requested Product Dispensed

D.DAW 9 — Substitution Allowed by Prescriber but Plan Requests Brand

Explanation: DAW (Dispense As Written) code 1 is used when the prescriber has specified brand necessary or dispense as written — substitution is not permitted. DAW 0 is the default when no substitution instruction is given, DAW 2 applies when the patient requests brand even though generic is allowed, and DAW 9 applies when the plan prefers brand (rare). DAW codes affect cost and copay.

10In 2026, what is the annual out-of-pocket maximum a Medicare Part D enrollee will pay before entering catastrophic coverage?

A.$2,100

B.$2,000

C.$3,500

D.$8,000

Explanation: Under the Inflation Reduction Act, Medicare Part D enrollees had a $2,000 out-of-pocket cap in 2025, which increased to $2,100 in 2026. Once a beneficiary's true out-of-pocket (TrOOP) reaches this threshold, they enter catastrophic coverage and pay $0 for covered Part D drugs for the rest of the plan year. The old 'donut hole' coverage gap was eliminated in 2025.

About the PTCB Billing & Reimbursement Exam

The PTCB Billing and Reimbursement Certificate is an Assessment-Based Certificate (ABC) program for active CPhTs who work with third-party billing, claim adjudication, prior authorization, and PBM audits. It is not a full certification — it recognizes specialized competency in pharmacy billing.

Questions

75 scored questions

Time Limit

1 hour 30 minutes

Passing Score

300 (scaled, 0-400)

Exam Fee

$89 (PTCB (Pharmacy Technician Certification Board))

PTCB Billing & Reimbursement Exam Content Outline

26.67%

Programs and Eligibility

Insurance types (HMO, PPO, Medicare Part B/D, Medicaid, TRICARE), third-party reimbursement basics, healthcare settings, patient eligibility verification, and coordination of benefits

36.67%

Pharmacy Claims Processing and Adjudication

NCPDP claim terminology, online claim submission, BIN/PCN/group/member ID fields, troubleshooting rejections, U&C vs AWP vs MAC pricing, DAW codes, and cost determination

18.33%

Prior Authorization

PA terminology, required clinical information, PA workflows, step therapy, quantity limits, formulary exceptions, and resolving PA denials

10.00%

Audits and Compliance

PBM audit types (desk, on-site, invoice), documentation requirements, HIPAA, FWA (fraud, waste, and abuse), record retention, and quality assurance

8.33%

Medical Claims Processing and Adjudication

Billable clinical services (immunizations, POC testing, MTM), medical claim terminology, CPT/HCPCS basics, Medicare Part B billing, and medical vs prescription coverage

How to Pass the PTCB Billing & Reimbursement Exam

What You Need to Know

Passing score: 300 (scaled, 0-400)
Exam length: 75 questions
Time limit: 1 hour 30 minutes
Exam fee: $89

Keys to Passing

Complete 500+ practice questions
Score 80%+ consistently before scheduling
Focus on highest-weighted sections
Use our AI tutor for tough concepts

PTCB Billing & Reimbursement Study Tips from Top Performers

1Memorize the most common NCPDP reject codes — especially 70 (product/service not covered), 75 (prior authorization required), 76 (plan limitations exceeded), 79 (refill too soon), and 88 (DUR reject error)

2Understand the 2026 Medicare Part D structure: $615 deductible max, $2,100 annual out-of-pocket cap, and elimination of the coverage gap (donut hole) under the Inflation Reduction Act

3Know the difference between Medicare Part B (physician-administered drugs, DME, nebulizers, diabetic supplies) and Part D (self-administered outpatient drugs)

4Practice coordination of benefits (COB) scenarios — primary vs secondary payer logic and how to submit the secondary claim with the other payer amount paid (OPAP)

5Learn DAW codes: DAW 0 (no product selection indicated), DAW 1 (substitution not allowed by prescriber), DAW 2 (patient requested brand), DAW 5 (brand dispensed as generic), DAW 9 (plan requires brand)

6Study BIN, PCN, group ID, and cardholder ID fields — know what each identifies on a pharmacy benefit card and what goes where in the NCPDP claim

7Understand PBM audit types (desk audit, on-site audit, invoice audit) and what documentation PBMs request — signed prescriptions, signature logs, invoices, and refill authorizations

8Review 340B basics — covered entities, contract pharmacy arrangements, carve-out requirements for Medicaid, and the duplicate discount prohibition

Frequently Asked Questions

Is the PTCB Billing and Reimbursement Certificate a full certification?

No. It is an Assessment-Based Certificate (ABC), not a full certification like CPhT or CSPT. PTCB's ABC programs recognize specialized competency in a specific pharmacy practice area. You must already hold an active PTCB CPhT credential to earn it. ABC holders can use the certificate to document specialty skills, but the CPhT remains the primary PTCB certification.

How much does the PTCB Billing and Reimbursement exam cost?

The exam fee is $89, significantly lower than the $129 PTCE (PTCB Certified Pharmacy Technician Exam). This reflects the narrower scope of the assessment-based certificate. You must also maintain your active CPhT certification (which has its own $129 application and biennial $49 recertification fee) to remain eligible.

What is the exam format and passing score?

Starting January 5, 2026, the exam contains 75 multiple-choice questions (up from 70). The total appointment time is 1 hour 30 minutes, which includes a 5-minute tutorial, 80 minutes of testing, and a 5-minute post-exam survey. Scores are reported on a 0 to 400 scale, and you must earn a scaled score of 300 or higher to pass.

Who is eligible to take the PTCB Billing and Reimbursement exam?

You must hold an active PTCB CPhT certification and satisfy one of two pathways: (1) complete a PTCB-Recognized Billing and Reimbursement education/training program AND have at least 6 months of pharmacy technician experience with 50% or more in billing and reimbursement, OR (2) have at least 12 months of full-time pharmacy technician work experience with 50% or more in billing and reimbursement. A supervisor attestation form is required.

What content is on the PTCB Billing and Reimbursement exam?

The 2026 blueprint has five knowledge areas: Programs and Eligibility (26.67%), Pharmacy Claims Processing and Adjudication (36.67%), Prior Authorization (18.33%), Audits and Compliance (10%), and Medical Claims Processing and Adjudication (8.33%). Pharmacy Claims Processing is the largest domain, covering NCPDP standards, adjudication, reject codes, and cost calculations.

What is the difference between the 2025 and 2026 exam versions?

Effective January 5, 2026, PTCB increased the question count from 70 to 75 and emphasized medical billing services offered by pharmacies, reflecting the expansion of pharmacy roles in immunizations, point-of-care testing, and medication therapy management. The scaled passing score (300) and appointment length (1 hour 30 minutes) are unchanged, but knowledge areas now include more detail and specific examples.

Is the PTCB Billing and Reimbursement Certificate worth it?

For pharmacy technicians working in billing-heavy roles (third-party billing, PA processing, specialty pharmacy, long-term care, or PBM operations), the certificate documents specialized competency and can support promotion, higher pay, or transition into billing specialist roles. Some employers reimburse the $89 fee. It is less valuable for techs who rarely touch third-party claims.

How long should I study for the PTCB Billing and Reimbursement exam?

Most candidates need 20 to 40 hours of focused study over 3 to 6 weeks. If you already process third-party claims daily, you can focus preparation on domains you touch less often (Prior Authorization, Audits and Compliance, Medical Claims). If you are newer to billing, plan on 40+ hours and work through a PTCB-Recognized training program.