Abstract:
A centralized formulary system for maintaining formulary data to service the needs of multiple user groups. Formulary and drug information is updated automatically when received from outside sources. In addition to drug identifying data, line of business and utilization management protocol data is associated with the formulary data. The formulary data further comprises coverage data for health plans that use the formularies. The additional business data maintained in association with the formularies facilitates the retrieval and editing of formulary data for various business needs, including compliance with third party requirements. The system allows users to analyze formulary data, edit formulary data, produce reports regarding formulary data, and export files. The system also supports submission of formulary data to third party computer systems.

Description:
CROSS-REFERENCE TO RELATED APPLICATIONS 
       [0001]    This application claims priority to U.S. Provisional Application Ser. No. 61/480,626, filed Apr. 29, 2011, titled CENTRALIZED FORMULARY SYSTEM AND METHOD, the content of which is incorporated by reference as if fully recited herein. 
     
    
     BACKGROUND OF THE INVENTION 
       [0002]    Drug formularies are commonly maintained by health benefits companies to track covered drugs for various health plans offered to different member groups. Formularies not only include the names of drugs, but details on each drug such as dosage instructions, quantity limits, drug tier information, therapeutic category, and SKU numbers. Each drug formulary may have tens of thousands of SKUs each identifying a different combination of drug details. 
         [0003]    Depending on the types of services a health benefits company offers, including different types of health plans, the company may need to maintain numerous formularies. For health benefit plans that are associated with government programs such as Medicare or Medicaid, the content of formularies may be regulated by the government. Other influences on the content of formularies include Food and Drug Administration (FDA) approval or disapproval of the safety of certain drugs, the availability of generic drugs versus brand name drugs, and the removal of drugs from the market by the manufacturer. All of these factors require companies to continually review and update the content of their formularies. A health benefits company that maintains numerous formularies may incur substantial costs in keeping the formularies updated and consistent for numerous user groups that require access to the formulary data for different purposes. User groups often need access to formulary in order to perform searches, access details about particular drugs, run reports, export information, or make their own changes to the formularies. 
         [0004]    User groups across a health benefits company may access and maintain formulary data in different ways. Some groups may rely on simple databases while others use spreadsheets. Various computer tools and systems are employed so that the groups can maintain not only drug details but also utilization management, insurance plan, and other coverage details such as co-pay requirements, prior authorization requirements, quantity limits, step requirements, etc. One common source for formulary coverage details is a claims processor that uses coverage information in processing member prescription claims. Claims processor data may be updated frequently to reflect changes in drug dosages and pricing as well as plan coverage. The claims processor data, which is used to process transactions, is not readily accessible to employees and agents of the health benefits company that manage and develop health plans and benefits. Data changes reflected in the claims processor may be communicated upon request to one or more user groups but there is no consistent or systematic approach for accessing and obtaining current data. 
         [0005]    Regardless of the types of computer tools or systems that are used, it is problematic when different user groups obtain and maintain formulary and coverage data in different ways (e.g., databases, spreadsheets, e-mail messages) from different sources (e.g., claims processor, other groups) as it increases the likelihood that a particular user group is accessing outdated formulary and coverage data. Furthermore, any changes made by one user group may not be communicated to other user groups unless the user groups collectively make a concerted effort to communicate changes. The pressure to keep formularies current is further exacerbated by the need for health benefit companies to send accurate formulary information to third party vendors and other entities that facilitate providing services to members. It is also important for a health benefits company to be able to share current and consistent formulary data with members so that members remain informed about the drugs covered by a particular health plan and the level of coverage provided. 
       SUMMARY OF THE INVENTION 
       [0006]    The present invention is a computerized system for managing formulary data, including automatically updating formulary data as new formulary data is received from outside sources, and allowing multiple users to access formulary data for different purposes. In one embodiment, a server receives formulary data about a plurality of formularies from a first source, receives drug information from a second source, stores the information in a database, provides multiple users with access to the stored information, receives instructions from the users and changes stored information based on those instructions, exports files containing formulary information, and supports an online formulary search for multiple remote users. The formulary data may be combined with utilization management protocol and coverage data so that the database comprises information about prior authorization groups, step therapy groups, related context drug lists, drug dosage information, drug codes, and drug cost information. In some embodiments, the centralized system allows users to create new formularies and formulary identification information. In some embodiments, the system audits all changes to formulary information made by users. The system may also allow users to produce reports regarding formulary information. The system may also track approvals made by different user groups regarding information that is to be submitted to remote locations. The system may further support an online drug search in which computer users can review formulary information associated with different health benefit plans. 
     
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         [0007]      FIG. 1  is a sample home page of a web interface of an example embodiment with a drug search tab; 
           [0008]      FIG. 2  is the sample home page and drug search tab of  FIG. 1  after a search has been completed; 
           [0009]      FIG. 3  is a sample copy formulary tab of a web interface of an example embodiment; 
           [0010]      FIG. 4  is a sample import formulary tab of a web interface of an example embodiment; 
           [0011]      FIG. 5  is a sample edit formulary tab of a web interface of an example embodiment; 
           [0012]      FIG. 6  is a sample related context lists tab of a web interface of an example embodiment; 
           [0013]      FIG. 7  is a sample context drug list search tab of a web interface of an example embodiment; 
           [0014]      FIG. 8  is the sample context drug list search tab of  FIG. 7  after a search has been completed; 
           [0015]      FIG. 9  is a sample drug-search tab of a web interface of an example embodiment shown along with the context drug list search tab of  FIG. 8 ; 
           [0016]      FIG. 10  is the sample drug-search tab of  FIG. 9  after a search has been run and results are listed; 
           [0017]      FIG. 11  is a sample new context drug list tab of a web interface of an example embodiment; 
           [0018]      FIG. 12  is a sample copy context drug list tab of a web interface of an example embodiment; 
           [0019]      FIG. 13  is a sample edit context drug list tab of a web interface of an example embodiment; 
           [0020]      FIG. 14  is a sample related formularies tab of a web interface of an example embodiment; 
           [0021]      FIG. 15  is a sample prescription drug guide report page of a web interface of an example embodiment; 
           [0022]      FIG. 16  is a sample import FRF tab of a web interface of an example embodiment; 
           [0023]      FIG. 17  is a sample PA group description search tab of a web interface of an example embodiment; 
           [0024]      FIG. 18  is a sample new PA group tab of a web interface of an example embodiment; 
           [0025]      FIG. 19  is a sample edit PA group tab of a web interface of an example embodiment; 
           [0026]      FIG. 20  is a sample related formularies tab of a web interface of an example embodiment; 
           [0027]      FIG. 21  is a sample step therapy group description tab of a web interface of an example embodiment; 
           [0028]      FIG. 22  is a sample edit ST group tab of a web interface of an example embodiment; 
           [0029]      FIG. 23  is a sample related formularies tab of a web interface of an example embodiment; 
           [0030]      FIG. 24  is a sample generate files tab of a web interface of an example embodiment; 
           [0031]      FIG. 25  is a sample approval tab of a web interface of an example embodiment; 
           [0032]      FIG. 26  is a sample clinical sign-off tab of a web interface of an example embodiment; 
           [0033]      FIG. 27  is a sample formulary ops approval tab of a web interface of an example embodiment; 
           [0034]      FIG. 28  is a sample confirm tab of a web interface of an example embodiment; 
           [0035]      FIG. 29  is a sample confirm results tab of a web interface of an example embodiment; 
           [0036]      FIG. 30  is a sample online provider drug list search page of a web interface of an example embodiment; 
           [0037]      FIG. 31  is a sample provider drug search results page of a web interface of an example embodiment; 
           [0038]      FIG. 32  is a system and logic diagram of an exemplary embodiment; and 
           [0039]      FIG. 33  is a block diagram of a centralized formulary process according to an example embodiment. 
       
    
    
     DETAILED DESCRIPTION 
       [0040]    One embodiment comprises a centralized formulary system that is automatically updated as formulary, drug, and coverage information is received from different sources. It may be accessed by different user groups through an on-line portal, and allows user groups to edit formulary information, create reports, and export information to remote systems. 
         [0041]    Referring to  FIG. 1 , a sample home page  10  of a web portal with an open drug search tab  12  of an example embodiment is shown. The home page  10  may be accessed by a user after logging into the web portal by providing a user name and password. On the home page  10 , the user can search the centralized formulary database and access different pull-down menus  14 , including Setup  16 , Reports  18 , Export  20 , health plan management system (HPMS) submission  22 , and claims processor submission  24 . The drug search tab  12  allows the user to perform formulary searches, and results may be filtered by selecting whether the plan with which the formulary is associated is active or inactive, and if active, whether it is a Medicare, Commercial, or Medicaid plan. An example of searchable fields that may appear in a drug search tab is shown in Appendix 1.0. Search results may be obtained at the Group Category Number (GCN) level, National Drug Category (NDC) level, or Step Therapeutic Category (STC) level. Examples of fields for search results at the GCN, NDC, and STC levels may be viewed in Appendices 1.1, 1.2, and 1.3, respectively. 
         [0042]    Referring to  FIG. 2 , the sample home page of  FIG. 1  is shown after a search request has been entered by the user. A user may filter the formulary results by selecting the check boxes  26  that correspond to active Medicare plans. In the example, Formulary  1000  has been selected from the list of Affected Formularies  28 , and an additional search criterion has been entered in the Drug Search tab  12 , particularly limiting the status of drugs to “Pending.” Results of this search are listed in a search results table  30  located below the Drug Search tab  12 . Formulary attributes may be viewed at different levels, including the National Drug Category (NDC) level, or hierarchy levels such as Group Category Number (GCN) and Step Therapeutic Category (STC) levels. Different levels may be viewed by selecting the desired level from the Hierarchy View pull-down tab  32 . 
         [0043]    The centralized formulary system allows a user to create a new formulary by accessing the Setup menu  16  and selecting an option to create a new formulary. In creating a new formulary, the system may require the user to enter formulary elements, including: formulary identifier; formulary name; formulary status; formulary format; number of tiers; line of business (e.g., Medicare, Commercial, Medicaid); type (open or closed); and description of the formulary. An example of new formulary criteria and field information is shown in the chart in Appendix 1.4. Upon entering the necessary information, the system may generate a new formulary with NDCs, unless the formulary status entered is “inactive.” The system may also store all information regarding creation and subsequent changes made to the formulary for audit purposes. 
         [0044]    The system may also allow a user to create a new formulary by copying an existing formulary. Referring to  FIG. 3 , a sample copy formulary tab  34  of an example embodiment is shown. This tab may be accessed through the Setup drop down menu  16  shown in  FIGS. 1 and 2 . A user can begin the copying process by entering a formulary identifier for an existing formulary into the formulary identifier search box  36 . The system searches for a corresponding identifier, and if found, presents information related to that formulary for validation by the user. When the user has found the formulary to be copied, a new formulary identifier may be entered and the new formulary is created. 
         [0045]    A new formulary may also be created by importing a formulary. Referring to  FIG. 4 , an import formulary tab  38  of an example embodiment is shown. This tab allows the user to enter criteria about the formulary as well as import the formulary file. An example of criteria and field guidelines is shown in Appendix 1.5. Once the user has specified the criteria and selected a file to import, selection of the Go button  40  imports the file into the system. An example of the fields and field criteria of a file that may be imported is included in Appendix 1.6. 
         [0046]    Formularies already existing in the centralized formulary system may be edited by a user. Referring to  FIG. 5 , an Edit Formulary tab  42  of an example embodiment is shown. This tab  42  may be accessed through the Setup drop down menu  16  shown in  FIGS. 1 and 2 . The user may enter the identifier of the formulary in the Enter Formulary identifier box  36 . Once the formulary has been located and the fields are populated on the edit formulary tab  42 , the user may update the information and save the changes. Examples of changes that may be made to a formulary include changing the number of tiers or updating the status from inactive to active. Many other changes may also be made through the edit formulary tab  42 . 
         [0047]    In some embodiments, the system creates new formularies and assigns a parent/child relationship to an existing formulary. In these embodiments, the system may store and display data to users that identifies the parent formulary of a child formulary, or vice versa. This feature is provided through the use of a parent identifier or child identifier field attached to each formulary. The system may also identify the differences between a parent formulary and child formulary on a per value basis and print reports identifying differences. Furthermore, in some embodiments edits made to a parent formulary&#39;s record may automatically be made to a child formulary&#39;s record as well. In different embodiments, the system may perform different functions based on the similarities or dissimilarities between parent/child formularies. 
         [0048]    The system allows a user to view context drug lists associated with a formulary, and change the relationship of context drug lists with the formulary. Context drug lists may override or add information to a formulary. For example, a context drug list may add a given attribute to some drugs on a formulary, such as mark all formulary drugs indicated for diabetes. A context drug list may override a formulary&#39;s included/excluded status on a drug (whether the drug is covered or not covered by a plan&#39;s formulary) or may override a formulary&#39;s brand/generic status on a drug (whether considered a brand or generic by a plan&#39;s formulary). 
         [0049]    The centralized formulary system may allow a user to view context drug lists related to formularies, and update the status of the relationship between context drug lists and formularies. Referring to  FIG. 6 , a related context lists tab  44  of an example embodiment is shown. Using this tab, the user can enter a formulary identifier and search to see which formularies have related context drug lists and which do not. Those that do not have related context drug lists may appear in the Not Related box  46 , while those that do have related context drug lists may appear in the Related box  48 . The user can also select a formulary and move it from one status to the other using the arrow buttons  50 . For example, the user can move a formulary from the Not Related Box  46  to the Related Box  48  and vice versa. 
         [0050]    Context drug lists may also be searched by a user. Referring to  FIG. 7 , a Context Drug List search tab  52  of an example embodiment is shown. A user may enter the name of a context drug list into the tab to see if any drug lists match the criteria. The user may select one of the drug lists, and then enter a search name and select a category to search for specific drugs. The categories may include: All (return all NDCs in the context drug list); DCC (Drug Class Category); STC, GCN (categories that expand to NDC); or NDC (NDC&#39;s display without a category). 
         [0051]    Referring to  FIG. 8 , the Context Drug List search tab  52  appears after a search is completed. A record list  54  shows the results of the search. Using the buttons on the record list, listed drugs may be edited or removed and drugs not listed may be added. Referring to  FIG. 9 , a Drug-Search tab  56  is shown along with the context drug list tab  52 . The Drug-Search tab may appear if a user has selected an option to add a drug. The user may search for a drug by entering a name and by selecting a category. The system may display available drugs responsive to the search in a results list  58  as shown in  FIG. 10 . The user may then select one of the drugs to add to the context drug list. 
         [0052]    If desired, a user may create a new context drug list. Referring to  FIG. 11 , a New Context Drug List tab  60  of an example embodiment is shown. This tab allows a user to enter information about the new context drug list, including a name, a purpose type, and a description. An example of fields and field criteria for an embodiment of a New Context Drug List tab  60  is set forth in Appendix 1.7. Once the user has entered the information and saved the changes, the list may be retrieved and edited. 
         [0053]    A new context drug list may also be created by copying an existing context drug list. Referring to  FIG. 12 , a Copy Context Drug List tab  62  of an example embodiment is shown. The user may enter the name of an existing list and provide a name for the new list to be created. Additional fields on this tab  62  may allow the user to validate the requested drug list. Once a user makes a copy and saves a new list with its new name, the user may then edit the new context drug list. 
         [0054]    Referring to  FIG. 13 , an Edit Context Drug List tab  64  of an example embodiment is shown. Using this tab, the user can search for the context drug list to edit, and then edit the different fields, including the purpose/type, and description. 
         [0055]    The system may also allow a user to view the formularies to which a particular drug list is related and update the status of the relationships. Referring to  FIG. 14 , a Related Formularies tab  66  of an example embodiment is shown. Using this tab, the user can search for a context drug list and view the formularies that are currently unrelated and related to that context drug list. The user may use the arrow buttons  50  to move formularies between the ‘not related’ box  46  and the ‘related’ box  48 . The changes may then be saved in the system. 
         [0056]    The system may perform automatic comparisons of the Non-Matched NDC List that is provided by the Center for Medicare and Medicaid Services (CMS) to the Food and Drug Administration (FDA) registry list and identify those NDCs that have become FDA listed in a predetermined time period and are also CMS approved. For example, the system may compare NDCs that have been FDA listed in the past 30 days and are also CMS approved. The system may also identify incremental changes, over a particular time period, for a particular NDC. This function may allow users to find products that have recently become FDA listed as well as review a NDC&#39;s history of changes. 
         [0057]    The system may automatically set the status of any NDC that has been FDA listed and CMS approved. For example, it may set the status of such NDC&#39;s to ‘pay.’ However, the system may also allow a user to override the automatic status of a NDC to a different status as desired. In doing so, the system may require the user to record a reason for the override, such as member impact, competitive intelligence, CMS update, or FDA update. The system may also require a user to type an effective date and end date for the change, and to select a value for the NDC at issue, such as Test NDC or Term NDC. Other information may also be required in order for a user to enter an override. 
         [0058]    Each month the system may automatically update FDA data, find changes in the data, and archive the prior month&#39;s status. In some embodiments, these functions may not be performed monthly, but on a different time schedule as desired. The system may also store additional information such as FDA alternatives, non-matched NDCs and alternatives within a particular GCN, and non-matched NDCs from CMS. FDA alternatives may be based on generic product indicator or electronic product code (GPI/EPC) logic, and taken from another source such as an electronic pharmacy list. 
         [0059]    The system may allow a user to export formulary data and create reports. One way in which the system may export data is in the form of a Prescription Drug Guide. This function may be accessed through the Export menu  20  on the Home Page  10 . The system may allow the user to select the contract year to be viewed, and the language, as well as other characteristics about the report. Once the user has selected the necessary criteria, the system displays the requested Prescription Drug Guide. Referring to  FIG. 15 , an example Prescription Drug Guide Report  68  according to an example embodiment is shown. As shown in  FIG. 15 , the Prescription Drug Guide Report may list Formulary identifiers, NDC information, Drug Names, Strengths, and Dosage Forms, as well as other information. The files generated by the system for the Prescription Drug Guide searched may be exported as a tab delimited file and saved for later use. An example of fields and field characteristics in an exported report is shown in Appendix 1.8. The system may also allow a user to export a printable drug list report. 
         [0060]    The system may also allow a user to create and export many different types of reports. Reports may be exported in tab delimited form to applications such as Microsoft Excel® or may be exported in other formats that are easily printable or viewable in different programs. Ad hoc reports may be generated regarding Formulary identifiers, NCDs, Label Names, Coverages, drug alternatives, or any combination. Analytic Reports may be generated for formularies. Audit reports may be generated to show creation, sign-off/confirmation, approval, change, deletion, relationship change, imports, and exports, or any combination thereof for a formulary, context drug list, or other type of file maintained by the system. Audit reports may include user identifier, date, time, action, relevant identifiers, and formulary maintenance-record status information. First Data Bank (FDB) reports may be generated on a variety of topics. Examples of FDB reports are provided in Appendix 1.9. 
         [0061]    The system may generate reports comparing formularies to one another. Formulary coverage reports may also be generated that display the percentage of drugs that are covered on that particular formulary, and the number and percentage of drugs that are on each tier. Formulary Reference File (FRF) change reports may be generated that show comparisons between two FRF files to identify additions, deletions, and any related NDC changes. Reports may also be generated showing non-matched NDCs that have become FDA listed. These reports may show changes made by users, including status changes and reasons for changes. Online drug lists may be compared in reports. Also, Prior Authorization (PA) and Step Therapy (ST) criteria for a drug may be generated by selecting a particular Formulary identifier. A ST criteria report may display each drug&#39;s name and its step therapy criteria. A PA criteria report may display drug names, covered uses, exclusion criteria, required medical information, age restrictions, prescriber restrictions, coverage duration, and any other criteria maintained in the system. Prescription plan reports may be generated to identify the formularies in a particular benefit plan. While the above provides examples of reports that may be generated by the system, it should be understood that in different embodiments the system may generate reports regarding any of the information it maintains, and the reports may be tailored for many different purposes. 
         [0062]    The system may allow a user to import a Formulary Reference File (FRF) that provides formulary updates. A FRF may be provided by the Centers for Medicare and Medicaid Services (CMS) on a monthly basis. A FRF may also be provided from a different source or at a different frequency. A FRF file may be imported by accessing the HPMS Submission menu  22  on the home page  10 . Referring to  FIG. 16 , an Import FRF tab  70  according to an example embodiment is shown. In this embodiment the Import FRF tab  70  not only allows the user to search for a FRF file based on a contract year, but the tab also displays the last  10  imported FRF files. 
         [0063]    The system may also allow a user to access, create, view, and edit Prior Authorization (PA) criteria as part of the HPMS submission process. Referring to  FIG. 17 , a PA Group Description Search tab  72  of an example embodiment is shown. This tab  72  may be accessed from the HPMS Submission menu  22 . Using this tab  72 , the user may enter a value into the search box, for example Lipitor, and receive a list of matching PA Group names. The PA Group Search tab  72  also allows a user to select a listed PA Group and edit its properties. New PA Groups can also be created. Referring to  FIG. 18 , a New PA Group tab  74  of an example embodiment is shown. This tab allows the user to fill in the fields required to create a new PA group. As shown in  FIG. 18 , the fields may include the PA group description, exclusion criteria, required medical information, age restrictions, prescriber restrictions, and coverage duration. When the user selects a save option, the new PA group is created. 
         [0064]    Existing PA Groups are edited in a similar manner. Referring to  FIG. 19 , an Edit PA Group tab  76  of an example embodiment is shown. This tab allows a user to make edits to an existing PA group and save the changes. 
         [0065]    The system may provide the user with information about which formularies are related to a particular PA Group, and update the relationship between formularies and the PA Group. Referring to  FIG. 20 , a Related Formularies tab  78  according to an example embodiment is shown. A user can enter the name of a PA Group into the search box, and the system identifies which formularies are related and which formularies are not related. If a user wishes to change the relationship of a particular formulary, the user can select that formulary and use the arrow buttons to move the formulary from one status to another. Changes to relationships can then be permanently saved in the system. 
         [0066]    The system may also allow users to work with Step Therapy (ST) Groups during the HPMS Submission process. Referring to  FIG. 21 , a ST Group Search tab  80  of an example embodiment is shown. Using this tab, a user may search for different ST Groups. The system may also allow a user to create a new ST Group. Whether a user creates a new group or accesses an existing group, the user may have the ability to edit information regarding the group. Referring to  FIG. 22 , a sample Edit ST Group tab  82  according to an example embodiment is shown. This tab allows a user to change the ST Criteria Change Indicator and the ST Criteria. In different embodiments, additional information regarding a ST Group may be maintained by the system and editable by a user. The Edit ST Group tab  82  not only allows a user to edit, but also allows a user to delete, a ST Group from the system by selecting the Remove option  84 . 
         [0067]    As with PA Groups, the relationship between ST Groups and formularies may be viewed by a user and updated. Referring to  FIG. 23 , a sample Related Formularies tab  86  according to an example embodiment is shown. This tab allows the user to view those formularies that are related and unrelated to a particular ST Group. This tab also allows the user to update the status of formularies and save the changes. 
         [0068]    It may be necessary for the system to generate files (formulary, PA, and ST files) for a third party, such as CMS, so that the third party can review and approve the content of the files before the health benefits company begins dispensing medications to its members. Reports that are created for sending to a third party, such as CMS, may be reviewed and validated prior to submission to ensure that they meet submission requirements. For example, a submission requirement may be that for every formulary there are at least two drugs in each American Hospital Formulary Service (AHFS) category and class, and that at least one of the two drugs is in a preferred tier (1 or 2). The system may allow a user to generate a report validating the two drug requirement. Such a report may identify any AHFS category and class that violates the requirement, and may also offer recommendations as to which drugs on a FRF should be used in the formulary in order to resolve the issue. Another example of a validation report is one that verifies all drugs in classes of clinical concern (such as antidepressants or antipsychotics) have the proper PA or ST type. Yet another example of a validation report is one that verifies no non-allowable changes have been made to the formulary since the last approved version. Non-allowable changes could include deletion of drugs or increasing tiers. 
         [0069]    When it comes time to actually submit a report to CMS or another third party, the system allows a user to generate the files to be sent. Referring to  FIG. 24 , a sample Generate Files tab  88  of an exemplary embodiment is shown. This tab allows the user to select a formulary, and then generate three different types of files: a formulary file; a PA file; or a ST file. Once a formulary file, PA file, or ST file is generated, the system may assign the related formulary to a “in desk review” status or other status to indicate to system users that the file has been generated and is being submitted to CMS or another third party. Examples of the format and fields in an exported formulary file, PA file, and ST is provided in Appendix 2.0, Appendix 2.1, and Appendix 2.2, respectively. 
         [0070]    Once submitted, the system may allow a user to track the CMS approval process. Referring to  FIG. 25 , a sample Approval tab  90  of an exemplary embodiment is shown. A user may enter a formulary identifier to search the system for formularies that are either waiting approval or have been approved. The system may provide the user with information regarding the version of the formulary, the type of files (formulary, PA, or ST), formulary date, status, and last approved formulary date. Once approval by CMS has been communicated to the health benefits company, a user may change the HPMS Formulary Status from “in desk review” to “approved.” While in this embodiment the user changes the status to “Approved,” in other embodiments CMS may communicate approval through a live feed to the system, and the status is automatically updated by the system without user intervention. The system may use the formulary data in the latest approved version to generate reports and provide data feeds to CMS or other third parties. 
         [0071]    A health benefits company may use data generated by the centralized formulary system to update a claims tracking database. The system may track data as claims are approved or denied at each stage. Data in the tracking database may include clinical sign-off information, formulary operations approval, and confirmation. 
         [0072]    Referring to  FIG. 26 , a sample Clinical Sign-off tab  92  of an exemplary embodiment is shown. This tab may be accessed from the claims processor (Argus Submission) menu  24  on the home page  10 . This tab  92  allows the user to search using different search options, including User identifier, GCN, NDC, or Formulary identifier. Different hierarchical views may be selected, including, for example, GCN to Formulary identifier to NDC 11, or Formulary identifier to GCN to NDC 11. The search results may be presented in a table that allows the user to perform an action for each level of records. For example, for each NDC 11 record, GCN record, and Formulary identifier record, the system may allow the user to either approve or deny. Records that are approved may then move to the next stage of the approval process, for example, they may be considered for formulary operations approval. If a user chooses to deny a record, the system may prompt the user to enter a reason for denial. Impacted drugs included on a denied record may remain in their last approved status. If there was no previous approval for a record, and the related formulary is closed, the system may set the record status to ‘not covered.’ If there was no previous approval for a record, and the related formulary is open, the system may set the record status to ‘covered.’ 
         [0073]    The formulary operations approval process may be similar to the Clinical Sign-Off approval process. Referring to  FIG. 27 , a sample formulary operations approval tab  94  of an example embodiment is shown. As with the Clinical Sign-Off tab  92 , this tab  94  allows the user to search for records based on different criteria, and gives the user the ability to approve or deny the resulting records. 
         [0074]    The last part of the submission process is to confirm the submission. Referring to  FIG. 28 , a sample Confirm tab  96  of an example embodiment is shown. Search criteria similar to those on the Clinical Sign-off tab  92  and Formulary Operations Approval tab  94  may be selected by the user. Also, a drop down type menu  98  may allow the user to search for updates of a particular type only. A search may be performed using all of the available search fields or just one or more. Once the user has selected search criteria and entered search terms, the results may be presented in a hierarchal view, for example, GCN (expandable) to Formulary identifier (expandable) to NDC 11. 
         [0075]    Referring to  FIG. 29 , a sample Confirm Results page  100  according to an example embodiment is shown. The search criteria entered in this particular example was 10079, GCN, and Tier. GCN and Formulary identifier levels may be expanded to reveal all levels down to the NDC. For each NDC level the following fields may be returned: NDC 11; Label Name; GPI; and Coverage. Additional information regarding each NDC may be present to show what changed on each record. In  FIG. 29 , the Lipitor record shows a tier value change from 1 to 2. If multiple changes have occurred to the same NDC, the Confirm Results page  100  may list each change as a separate record. As shown in  FIG. 29 , each level of the search results may provide the user with the same options for entering information regarding that record. The claims processor target date is the date that the user would like to get a deployment confirmation email from the claims processor. The claims processor completion date is the actual date the data was successfully deployed in the claims processor. Comments allow a user to explain why a row has been denied, if that action is taken. These are simply examples of information that may be recorded, and in different embodiments different types of information regarding each record may be recorded. 
         [0076]    As shown in  FIG. 29 , each record allows the user to choose a certain action. Confirm may allow a user to save the record and change the record status to “confirmed.” The “deny” option may allow the user to clear the claims processor target Date or claims processor completion date fields, create a record of the cleared data for audit purposes, and allow the user to input new data. The “deploy” option sets the status of the record to “deployed”. This data can be subsequently tracked by generating a formulary deploy report. Once the claims processor has received and processed the data that has been deployed, a user can update the claims processor completion data fields. While in some embodiments a user may receive confirmation from the claims processor via emails, in some embodiments the claims processor may submit confirmation information to the system via a live feed, and the claims processor completion data fields may be updated automatically. For data that was not deployed, a user may enter the reason in the comments field and select the deny option. 
         [0077]    The system may track drugs to ensure drug safety. For example, the system may track drugs to ensure that drugs are not repackaged, and are not obsolete. The point at which a drug is obsolete may be once the obsolete date is more than two years older than the current date. When a formulary&#39;s status is changed from inactive to active, the system may automatically remove NDCs that are no longer on the First Data Bank, have become a repackaged drug, have become obsolete, have switched to an over-the-counter indication, or met some other type of criteria that is monitored by the system. Logic that may be used by the system to identify NDCs that need to be removed is shown in Appendix 2.3. 
         [0078]    The system may provide an online drug list that can be accessed by a healthcare benefit company&#39;s member. Using the web, a member may select the type of health plan and select a particular drug to see whether that drug is covered by the health plan. Referring to  FIG. 30 , a sample online drug list search page  102  according to an example embodiment is shown. This page allows a user to select a drug plan category (for example, Medicare Plans) and then search for a drug either by name, alphabetically, or by therapeutic class. Referring to  FIG. 31 , a sample provider drug search results page  104  of an example embodiment is shown. The results shown on this page  104  are for the drug Plavix, and its coverage under different Medicare plans. Also shown are possible alternatives for Plavix. The system may run the online drug list by creating multiple web files for the Context Drug list, Formulary Information, Drug Information, Alternative Logic, and Conditions. The system may extract drug data for the online drug list on a periodic basis, such as once a week, and create multiple web files to support the online drug list application. Examples of data elements and rules for web files, including a Context drug list, formulary information, drug information, alternative logic, and condition, is shown in Appendices 2.4 through 2.8. 
         [0079]    Referring to  FIG. 32 , a system and logic diagram of an exemplary embodiment is shown. In this system, a centralized formulary server  106  maintained by a healthcare benefits company contains a database for formulary data. The centralized formulary server  106  also maintains the on-line web portal for user groups associated with the healthcare benefits company to access and use formulary data as necessary. Multiple users may access the on-line web portal simultaneously, and user access to different type of formulary data and the ability to edit formulary data may be restricted depending on the user or user group. In some embodiments, any user trying to access the system must provide a user name and password. The centralized formulary server  106  also maintains the on-line drug list that is accessible via the internet to health care benefits member and/or the public at large. In some embodiments the on-line drug list may only be accessible to healthcare benefits company members who must enter a username and password in order to access the drug list. 
         [0080]    The centralized formulary server  106  may receive data relative to drug formularies from one or more remote locations. The Centers for Medicare and Medicaid Services (CMS) server  108  may provide Formulary Reference Files (FRFs) to the centralized formulary server  106  over a secure network. FRF files may be received on a monthly basis or at a different frequency as needed. The CMS server  108  receives Health Plan Management System (HPMS) Submissions from the centralized formulary server  106  and also communicates to the centralized formulary server  106  when HPMS Submissions have been approved. A server  110  maintained by The Food and Drug Administration (FDA) provides data to the centralized formulary server  106  regarding the registry list. 
         [0081]    Another remote source that the centralized formulary server receives data from is the First Data Bank server  112 . This server  112  accesses the First Data Bank database and forwards National Drug Data Files (NDDFs) to the centralized formulary server  106 . NDDFs include data regarding medication identifiers, drug descriptions, drug dosages, and form of dosages. The First Data Bank server  112  may provide data on a weekly basis or at another frequency as needed. 
         [0082]    A claims tracking database  114  may be located remotely to the centralized formulary server  106 . Formulary data is sent from the centralized formulary server  106  to the claims tracking database  114 . Reports generated by the centralized formulary system  106  may also be sent to the claims tracking database  114  for e-Prescribing purposes. The claims tracking database  114  may send data to the centralized formulary server  106  as well, including Generic Product Identifier (GPI) override files. 
         [0083]    Referring to  FIG. 33 , a block diagram of a centralized formulary process according to an example embodiment is shown. In an example embodiment, a centralized formulary process  120  comprises a formulary build process  122 , a formulary maintenance process  124 , a formulary submission process  126 , and a formulary distribution process  128 . Centralized formulary input processes include the formulary build  122  and formulary maintenance  124  processes. The build process  122  supports creation and maintenance of formulary lists while the maintenance process  124  supports specific drug list changes. The submission process  126  provides functionality for developing and submitting formularies to CMS for approval. The distribution process  128  provides functionality for distributing formularies to lines of businesses, third party computer systems, etc. In one example, the formulary distribution process  128  supports a formulary data feed to a drug database  132  that supports a web application  130  for viewing information about the drugs on the formulary. The feed provides current formulary data for the drug database which may have pricing and other data relevant to a health plan. A user at the web site may view data from the formulary to determine drug coverage. The formulary distribution process  128  may also provide file export functionality to provide formulary files for a prescription validation  134  and e-prescription processing  138 . The distribution process may be modified as needed to ensure that current formulary data is distributed throughout an organization according to the specific needs of multiple lines of business. 
         [0084]    While certain embodiments of the present invention are described in detail above, the scope of the invention is not to be considered limited by such disclosure, and modifications are possible without departing from the spirit of the invention as evidenced by the claims. One skilled in the art would recognize that such modifications are possible without departing from the scope of the claimed invention. 
       APPENDICES 
       [0085]      
         [0000]    
       
         
               
             
               
               
             
           
               
                 APPENDIX 1.0 
               
             
             
               
                   
               
               
                 Example of Searchable Fields on Drug Search Tab 
               
             
          
           
               
                 Field Name 
                 Type and Maximum Length 
               
               
                   
               
               
                 Drug Name 
                 20 alphanumeric characters 
               
               
                 NDC 
                 11 numeric characters, system can search with 
               
               
                   
                 only 9 
               
               
                 RXCUI 
                 6 numeric characters 
               
               
                 GCN 
                 5 numeric characters, exact match only 
               
               
                 Status 
                 Pending, Clinical Sign-off, Approved, Confirmed 
               
               
                 Tier 
                 0, 1, 2, 3, 4, 5, 6 
               
               
                 Prior Authorization 
                 0, 1, 2, 3 
               
               
                 Argus GPI 
                 0, 1, 2, 3 
               
               
                 Quantity Limits 
                 4 numeric characters 
               
               
                 Step Therapy Step 
                 0, 1, 2 
               
               
                 Value 1 
               
               
                 Step Group 1 
                 Pop box of ST Groups linked to the selected 
               
               
                   
                 formulary 
               
               
                 Step Therapy Step 
                 0, 1, 2 
               
               
                 Value 2 
               
               
                 Step Group 2 
                 Pop up box of ST Groups linked to the selected 
               
               
                   
                 formulary 
               
               
                 PA Group 
                 Pop up box of available PA Group descriptions 
               
               
                 Hierarchy View 
                 None, STC, GCN, MedID 
               
               
                 Gender Edits 
                 M, F 
               
               
                 Age Edits 
                 Yes/No Returns records with data in the Age Edit 
               
               
                   
                 field 
               
               
                 Proxy View only 
                 Check box 
               
               
                   
               
             
          
         
       
     
         [0000]    
       
         
               
             
               
               
             
           
               
                 APPENDIX 1.1 
               
             
             
               
                   
               
               
                 Example of Fields for Search Results at GCN Level 
               
             
          
           
               
                 Field Name 
                 Type and Maximum Length 
               
               
                   
               
               
                 Formulary ID 
                   
               
               
                 GCN 
               
               
                 Covered 
                 Y or N 
               
               
                 Tier 
                 1, 2, 3, 4, 5, 6 
               
               
                 PA 
                 0, 1, 2, 3 
               
               
                 PA Group 
                 Pop up box of PA Groups linked to the selected 
               
               
                   
                 formulary - Changes trigger 
               
               
                   
                 a status change to Pending. 
               
               
                 QL 
                 Y or -If Y, QL Amt and QL DS become required 
               
               
                   
                 fields. 
               
               
                 QL Amt 
                 4 characters 
               
               
                 QL DS 
                 10 characters 
               
               
                 QL Dacon 
                 6 characters 
               
               
                 Step Therapy Type 
               
               
                 Step Preclusive 
                 Y or N 
               
               
                 Step Therapy Value 1 
                 0, 1, 2 
               
               
                 Step Therapy Group 1 
                 Pop up box of ST Groups linked to the selected 
               
               
                   
                 formulary - Changes trigger 
               
               
                   
                 a status change to Pending. 
               
               
                 Step Therapy Value 2 
                 0, 1, 2 
               
               
                 Step Therapy Group 2 
                 Pop up box of ST Groups linked to the selected 
               
               
                   
                 formulary - Changes trigger 
               
               
                   
                 a status change Pending. 
               
               
                 Age Min. 
                 10 characters 
               
               
                 Age Max 
                 10 characters 
               
               
                 Gender 
                 M or F 
               
               
                 GPI 
               
               
                 GI 
               
               
                 Status 
               
               
                 Action 
               
               
                   
               
             
          
         
       
     
         [0000]    
       
         
               
             
               
               
             
           
               
                 APPENDIX 1.2 
               
             
             
               
                   
               
               
                 Example of Fields for Search Results at NDC Level 
               
             
          
           
               
                 Field Name 
                 Type and Maximum Length 
               
               
                   
               
               
                 Formulary ID 
                   
               
               
                 NDC 11 
               
               
                 Drug Name 
               
               
                 Label Name 
               
               
                 Covered 
                 Y or N 
               
               
                 Tier 
                 1, 2, 3, 4, 5, 6 
               
               
                 PA 
                 0, 1, 2, 3 
               
               
                 PA Group 
                 Pop up box of PA Groups linked to the selected 
               
               
                   
                 formulary - Changes trigger 
               
               
                   
                 a status change to Pending. 
               
               
                 QL 
                 Y or -If Y, QL Amt and QL DS become required 
               
               
                   
                 fields. 
               
               
                 QL Amt 
                 4 characters 
               
               
                 QL DS 
                 10 characters 
               
               
                 QL Dacon 
                 6 characters 
               
               
                 Step Therapy Type 
               
               
                 Step Preclusive 
                 Y or N 
               
               
                 Step Therapy Value 1 
                 0, 1, 2 
               
               
                 Step Therapy Group 1 
                 Pop up box of ST Groups linked to the selected 
               
               
                   
                 formulary - Changes trigger 
               
               
                   
                 a status change to Pending. 
               
               
                 Step Therapy Value 2 
                 0, 1, 2 
               
               
                 Step Therapy Group 2 
                 Pop up box of ST Groups linked to the selected 
               
               
                   
                 formulary - Changes trigger 
               
               
                   
                 a status change to Pending. 
               
               
                 Age Min. 
                 10 characters 
               
               
                 Age Max 
               
               
                 Gender 
                 M or F 
               
               
                 GPI 
               
               
                 GI 
               
               
                 Status 
               
               
                 Action 
               
               
                   
               
             
          
         
       
     
         [0000]    
       
         
               
             
               
               
             
           
               
                 APPENDIX 1.3 
               
             
             
               
                   
               
               
                 Example of Fields for Search Results at STC Level 
               
             
          
           
               
                 Field Name 
                 Type and Maximum Length 
               
               
                   
               
               
                 Formulary ID 
                   
               
               
                 STC 
               
               
                 Covered 
                 Y or N 
               
               
                 Tier 
                 1, 2, 3, 4, 5, 6 
               
               
                 PA 
                 0, 1, 2, 3 
               
               
                 PA Group 
                 Pop up box of PA Groups linked to the selected 
               
               
                   
                 formulary - Changes trigger 
               
               
                   
                 a status change to Pending. 
               
               
                 QL 
                 Y or -If Y, QL Amt and QL DS become required 
               
               
                   
                 fields. 
               
               
                 QL Amt 
                 4 characters 
               
               
                 QL DS 
                 10 characters 
               
               
                 QL Dacon 
                 6 characters 
               
               
                 Step Therapy Type 
               
               
                 Step Preclusive 
                 Y or N 
               
               
                 Step Therapy Value 1 
                 0, 1, 2 
               
               
                 Step Therapy Group 1 
                 Pop up box of ST Groups linked to the selected 
               
               
                   
                 formulary - Changes trigger 
               
               
                   
                 a status change to Pending. 
               
               
                 Step Therapy Value 2 
                 0, 1, 2 
               
               
                 Step Therapy Group 2 
                 Pop up box of ST Groups linked to the selected 
               
               
                   
                 formulary - Changes trigger 
               
               
                   
                 a status change Pending. 
               
               
                 Age Min. 
                 10 characters 
               
               
                 Age Max 
               
               
                 Gender 
                 M or F 
               
               
                 GPI 
               
               
                 GI 
               
               
                 Status 
               
               
                 Action 
               
               
                   
               
             
          
         
       
     
         [0000]    
       
         
               
             
               
               
             
           
               
                 APPENDIX 1.4 
               
             
             
               
                   
               
               
                 Example of Fields for a New Formulary page 
               
             
          
           
               
                 Field Name 
                 Allows . . . 
               
               
                   
               
               
                 Formulary ID 
                 You to create a 10 alphanumeric character ID 
               
               
                 Formulary Name 
                 You to create a 40 alphanumeric character name 
               
               
                 Formulary Status 
                 Active, Inactive 
               
               
                   
                 Note: Formularies with an aActive status are 
               
               
                   
                 maintained with batch FDB updates. 
               
               
                 Formulary Format 
                 CY 2009, CY 2010, CY 2011, Commercial 
               
               
                 # of tiers 
                 0, 1, 2, 3, 4, 5, 6 
               
               
                 Line of Business 
                 Medicare, Commercial, Medicaid 
               
               
                 Type 
                 Open, Closed 
               
               
                   
                 Note: Defaults to Open. All drugs in an open 
               
               
                   
                 formulary are covered. All drugs in a closed 
               
               
                   
                 formulary are not covered. However, these open 
               
               
                   
                 and closed formularies can have a drug&#39;s status 
               
               
                   
                 overridden by Include and Exclude Context Drug 
               
               
                   
                 Lists. 
               
               
                 Description 
                 You to type 256 alphanumeric characters 
               
               
                 Created Date 
                 System generated 
               
               
                 Created By 
                 System generated 
               
               
                 Copied From 
                 You to type a 10 alphanumeric character name or 
               
               
                   
                 ID. 
               
               
                 Argus Formulary 
                 You to create a 10 alphanumeric character ID. 
               
               
                   
               
             
          
         
       
     
         [0000]    
       
         
               
             
               
               
             
           
               
                 APPENDIX 1.5 
               
             
             
               
                   
               
               
                 Example of fields for an Import Formulary page 
               
             
          
           
               
                 Field Name 
                 Allows . . . 
               
               
                   
               
               
                 Formulary ID 
                 You to create a 10 alphanumeric character ID 
               
               
                 Formulary Name 
                 You to create a 40 alphanumeric character name. 
               
               
                 Formulary Status 
                 Active, Inactive 
               
               
                 Formulary Format 
                 CY 2009, CY 2010, CY 2011, Commercial 
               
               
                 # of tiers 
                 0, 1, 2, 3, 4, 5, 6 
               
               
                 Line of Business* 
                 Medicare, Commercial, Medicaid 
               
               
                 Type 
                 Open, Closed 
               
               
                   
                 Note: Defaults to Open. All drugs in an Open 
               
               
                   
                 formulary are covered. All drugs in a Close 
               
               
                   
                 Formulary are not. 
               
               
                 Argus Formulary ID 
                 You to create a 10 alphanumeric character ID. 
               
               
                 Browse to import file 
                 You to click Browse, select the formulary text file 
               
               
                   
                 you want to upload, and click Go. 
               
               
                   
               
             
          
         
       
     
         [0000]    
       
         
               
             
               
               
               
               
             
               
               
               
               
             
           
               
                 APPENDIX 1.6 
               
             
             
               
                   
               
               
                 Example of Fields that Are Uploaded When a Formulary is Imported 
               
             
          
           
               
                   
                 Max. 
                   
                   
               
               
                 Field Name 
                 Length 
                 Description 
                 Sample Value(s) 
               
               
                   
               
             
          
           
               
                 NDC 
                 11 
                 National Drug Category Number 
                 00123476546 
               
               
                 RXCUI 
                 8 
                 RxNorm identifier from the active 
                 210597 
               
               
                   
                   
                 Formulary Reference File. 
               
               
                 Coverage Status/Cvg/ 
                 1 
                 Indicates whether the NDC is covered 
                 Y 
               
               
                 Covered 
                   
                 in the formulary. 
                 N 
               
               
                   
                 2 
                 Defines the Cost Share Tier Level 
                 1 = Tier Level 1 
               
               
                   
                   
                 associated with the drug. 
                 2 = Tier Level 2 
               
               
                   
                   
                 Note: Assumes each drug is assigned 
                 3 - Tier Level 3 
               
               
                   
                   
                 to only one tier value. 
                 4 = Tier Level 4 
               
               
                   
                   
                   
                 5 = Tier Level 5 
               
               
                   
                   
                   
                 6 = Tier Level 6 
               
               
                 Drug Type Label 
                 1 
                 Indicates the drug&#39;s type label. 
                 1 = Generic 
               
               
                   
                   
                 From the list of labels (right), enter the 
                 2 = Preferred Generic 
               
               
                   
                   
                 label value for the Drug Type. 
                 3 = Non-Preferred 
               
               
                   
                   
                   
                 Generic 
               
               
                   
                   
                   
                 4 = Brand 
               
               
                   
                   
                   
                 5 = Preferred Brand 
               
               
                   
                   
                   
                 6 = Non-Preferred 
               
               
                   
                   
                   
                 Brand 
               
               
                 Quantity Limits/QL YN 
                 1 
                 Does the drug have a quantity limit 
                 0 = No Quantity limits 
               
               
                   
                   
                 restriction? 
                 1 = Quantity Limits 
               
               
                   
                   
                   
                 Apply 
               
               
                 Quantity Limit Amount/ 
                 7 
                   If the Quantity Limit is 1, type 
                 9 grams 
               
               
                 QL Amt 
                   
                   the quantity limit unit amount for 
               
               
                   
                   
                   a given Rx or time period. 
               
               
                   
                   
                   These units must be defined by 
               
               
                   
                   
                   a unit of measure such as: 
               
               
                   
                   
                   number of tablets, millimeters, 
               
               
                   
                   
                   grams and so on. 
               
               
                   
                   
                   If the Quantity Limit is 0, leave 
               
               
                   
                   
                   this field blank. 
               
               
                   
                   
                 The maximum number of decimal points 
               
               
                   
                   
                 accepted is 5. 
               
               
                   
                   
                 Example 
               
               
                   
                   
                 9.99999 
               
               
                 Quantity Limit Days/QL 
                 3 
                 The number of days associated with the 
               
               
                 DS 
                   
                 quantity limit. The maximum number 
               
               
                   
                   
                 accepted is 999. 
               
               
                   
                   
                 Exception 
               
               
                   
                   
                 If the Quantity Limit field is 0, leave this 
               
               
                   
                   
                 field blank. 
               
               
                 Prior Authorization Type 
                 1 
                 Is prior authorization required for the 
                 0 = No Prior 
               
               
                 (PA) 
                   
                 drug? 
                 Authorization 
               
               
                   
                   
                   
                 1 = Prior 
               
               
                   
                   
                   
                 Authorization Applies 
               
               
                   
                   
                   
                 2 = Prior 
               
               
                   
                   
                   
                 Authorization Applies 
               
               
                   
                   
                   
                 to New Stats Only 
               
               
                   
                   
                   
                 3 = Part B vs. Part D 
               
               
                   
                   
                   
                 Prior Authorization 
               
               
                   
                   
                   
                 Only 
               
               
                 Prior Authorization 
                 100 
                 Description of the drug&#39;s prior 
                 Antiemetics 
               
               
                 Group Desc/Group/PA 
                   
                 authorization group as it will appear on 
               
               
                 Group 
                   
                 the submitted prior authorization 
               
               
                   
                   
                 attachment. The group name may 
               
               
                   
                   
                 represent a drug category, class, or (if 
               
               
                   
                   
                 no other grouping structure applies) 
               
               
                   
                   
                 may simply be the name of the drug. 
               
               
                   
                   
                 If the Prior Authorization Type is 0 or 3, 
               
               
                   
                   
                 then this field is blank. 
               
               
                 Limited Access? 
                 1 
                 Is access to this drug limited to certain 
                 1 = Yes 
               
               
                   
                   
                 pharmacies? 
                 0 = No 
               
               
                 Therapeutic Category 
                 100 
                 Name of the drug&#39;s Category. 
                 Analgesics 
               
               
                 Name 
               
               
                 Therapeutic Class 
                 100 
                 Name of the drug&#39;s Class 
                 Opioid analgesics 
               
               
                 Name 
               
               
                 QL Decon 
                 4 
                 A Quantity Limit Average Daily 
                 Examples 
               
               
                   
                   
                 Consumption applies to oral tablets or 
                 30/30 is equal to 1 
               
               
                   
                   
                 capsules and promotes cost-efficient 
                 cap per 1 day, 1 cap 
               
               
                   
                   
                 regimens for drugs dosed once daily 
                 divided by .75 = 1.3 
               
               
                   
                   
                 when multiple strengths are similarly 
                 or Dacon of 1.333 
               
               
                   
                   
                 priced 
                 60/30 is equal to 2 
               
               
                   
                   
                   
                 caps per 1 day, 2 
               
               
                   
                   
                   
                 caps divided by .75 = 
               
               
                   
                   
                   
                 2.6 or Decon of 2.666 
               
               
                 Step Therapy Type/s 
                 1 
                 Does step therapy apply to this drug? 
                 0 = Not Part of a Step 
               
               
                 ST 
                   
                 Note: Prerequisite (Step 1) drugs also 
                 Therapy Program 
               
               
                   
                   
                 have a value of 1 in this field. 
                 1 = Step Therapy 
               
               
                   
                   
                   
                 Applies 
               
               
                   
                   
                   
                 2 = Step Therapy 
               
               
                   
                   
                   
                 Applies to New Starts 
               
               
                 Step Preclusive 
                   
                 Preclusive step therapy excludes the 
               
               
                   
                   
                 use of a drug or drug class when 
               
               
                   
                   
                 therapy is contraindicated with another 
               
               
                   
                   
                 drug or drug class. It can be used to 
               
               
                   
                   
                 develop customized drug/drug 
               
               
                   
                   
                 interaction edits or duplicate therapy 
               
               
                   
                   
                 edits. 
               
               
                 Step Therapy Total 
                 2 
                 The total number of step therapy drug- 
                 3 
               
               
                 Groups/Step Group 1 
                   
                 treatment groups in which the drug is 
               
               
                   
                   
                 included. The maximum number 
               
               
                   
                   
                 accepted is 99. 
               
               
                   
                   
                 If the Step Therapy Type is 0, then this 
               
               
                   
                   
                 field is bank. 
               
               
                 Step Therapy Group 
                 100 
                 Description of the step therapy drug 
                 CHF Therapy 
               
               
                 Desc 
                   
                 treatment group. 
                 Angina Therapy 
               
               
                   
                   
                 If the Step Therapy Type is 0, this field 
                 CVD Therapy 
               
               
                   
                   
                 should be blank. 
               
               
                   
                   
                 Note: For a given RXCUI, each ST 
               
               
                   
                   
                 Group Description must be unique. 
               
               
                 Step Therapy Step 
                 2 
                 Identifies the step number or level 
                 4 
               
               
                 Value/ST step value 1/ 
                   
                 within the sequence for the Step 
                 Example 
               
               
                 value 2 
                   
                 Therapy Group. The range of accepted 
                 Step 4 of 6 
               
               
                   
                   
                 values is 1 to 99. 
               
               
                   
                   
                 This field is repeated in the record 
                 1 
               
               
                   
                   
                 (based on the numerical value in the 
                 Example 
               
               
                   
                   
                 Step Therapy Total Groups field) and in 
                 Step 1 of 3 
               
               
                   
                   
                 the same order as the list of values 
               
               
                   
                   
                 given for the Step Therapy Group Desc 
               
               
                   
                   
                 field. 
               
               
                   
                   
                 If the Step Therapy Type is 0, this field 
                 5 
               
               
                   
                   
                 is blank. 
                 Example 
               
               
                   
                   
                   
                 Step 5 of 5 
               
               
                 GPI 
                 1 
                 A Generic Product Identifier labels a 
                 1 = Generic 
               
               
                   
                   
                 drug either generic or brand 
                 2 = Brand 
               
               
                 GI 
                 1 
                 A Generic Indicator indicates a drug&#39;s 
                 1 = Multi-source 
               
               
                   
                   
                 number of manufactures. For example, 
                 product 
               
               
                   
                   
                 brand drugs are normally from a single 
                 2 = Single-source 
               
               
                   
                   
                 manufacturer while generic drugs are 
                 product 
               
               
                   
                   
                 often manufactured by several 
               
               
                   
                   
                 companies. 
               
               
                   
               
             
          
         
       
     
         [0000]    
       
         
               
             
               
               
             
           
               
                 APPENDIX 1.7 
               
             
             
               
                   
               
               
                 Example of Fields and Field Criteria for New Context Drug List 
               
             
          
           
               
                 Field Name 
                 Allows . . . 
               
               
                   
               
               
                 Context Drug List 
                 You to create a 30 alphanumeric character ID. 
               
               
                 Name 
               
               
                 Purpose/Type 
                 Informational (Info List), B/G, Include, Exclude 
               
               
                   
                 If you select Info List, CF displays its Secondary 
               
               
                   
                 Info Type drop-down. Selecting one of its values is 
               
               
                   
                 optional: 
               
               
                   
                   Maintenance Coverage in the Gap 
               
               
                   
                   Abbreviated Drug Guide 
               
               
                   
                   Printable Drug List 
               
               
                   
                   Home Infusion Coverage in the Gap 
               
               
                   
                   Diabetes Coverage in the Gap 
               
               
                   
                   Preferred Diabetic Supplies 
               
               
                   
                   Non-Preferred Diabetic Supplies 
               
               
                   
                   ED 
               
               
                   
                   Benzo/Barb 
               
               
                   
                   ED/BB 
               
               
                   
                   Specialty Drug 
               
               
                 Description 
                 You to type 255 alphanumeric characters. 
               
               
                 Argus Drug List ID 
                 Not in use at this time. 
               
               
                   
               
             
          
         
       
     
         [0000]    
       
         
               
             
               
               
               
               
               
             
           
               
                 APPENDIX 1.8 
               
             
             
               
                   
               
               
                 Exemplary Format of Export Prescription Drug Guide 
               
             
          
           
               
                   
                   
                   
                   
                 Business 
               
               
                   
                   
                   
                 Sample Field 
                 Rules/Reference 
               
               
                 Field Name 
                 Field type 
                 Field Description 
                 Value(s) 
                 Sources 
               
               
                   
               
               
                 Formulary ID 
                 CHAR 
                 5-Digit HPMS 
                 10079-Puerto Rico 
                 A formulary ID 
               
               
                   
                   
                 Formulary ID 
                 10080- Value 
                 must be on every 
               
               
                   
                   
                   
                 10091 - Standard 
                 drug on a 
               
               
                   
                   
                   
                 10082 - National 
                 formulary 
               
               
                   
                   
                   
                 10084 - Plus 
               
               
                   
                   
                   
                 10085 - Select 
               
               
                 Proxy NDC 
                 CHAR 
                 11-digit National 
                 000003338000 
                 Convert RxCUI to 
               
               
                   
                   
                 Drug Code 
                   
                 Related NDC 
               
               
                   
                   
                   
                   
                 using the FRF. 
               
               
                 Drug Name 
                 CHAR 
                 Name of drug: 
                 JANUVIA 
                 Since FRF does 
               
               
                   
                   
                 Brand = CAPS 
                 Acarbose 
                 not have drug 
               
               
                   
                   
                 Generic = lower 
                   
                 names, use BM 
               
               
                   
                   
                 case 
                   
                 field from First 
               
               
                   
                   
                   
                   
                 Data Bank (FDB). 
               
               
                   
                   
                   
                   
                 Also, use the 
               
               
                   
                   
                   
                   
                 Generic Pricing 
               
               
                   
                   
                   
                   
                 Indicator (GPI) to 
               
               
                   
                   
                   
                   
                 capitalize brand 
               
               
                   
                   
                   
                   
                 drug names. 
               
               
                 Strength 
                 CHAR 
                 Strength of drug 
                 10 MG 
                 Since FRF does 
               
               
                   
                   
                 listed 
                   
                 not have Strength, 
               
               
                   
                   
                   
                   
                 use Argus FRF. 
               
               
                 Dosage Form 
                 CHAR 
                 Drug form 
                 Tablet 
                 Since FRF does 
               
               
                   
                   
                   
                   
                 not have Dosage, 
               
               
                   
                   
                   
                   
                 use Argus FRF. 
               
               
                 HIDO Value 
                 CHAR 
                 SNIP plan 
                 D = diabetes 
                 D = Reference 
               
               
                   
                   
                 indicator 
                 H = Home Infusion 
                 Diabetes Context 
               
               
                   
                   
                   
                 M = Maintenance 
                 List 
               
               
                   
                   
                   
                 GC = Gap 
                 H = Ref. Home 
               
               
                   
                   
                   
                 Coverage 
                 Infusion Context 
               
               
                   
                   
                   
                 NM = Non Mail- 
                 List 
               
               
                   
                   
                   
                 Order 
                 M = Ref. 
               
               
                   
                   
                   
                   
                 Maintenance Meds 
               
               
                   
                   
                   
                   
                 Context Drug List 
               
               
                   
                   
                   
                   
                 GC = All tier 1 
               
               
                   
                   
                   
                   
                 drugs for 10082, 
               
               
                   
                   
                   
                   
                 10084, and 10085 
               
               
                   
                   
                   
                   
                 NM = Ref. Non 
               
               
                   
                   
                   
                   
                 Mail Context List 
               
               
                 Tier Level 
                 CHAR 
                 Defines the cost 
                 1 = Tier Level 1 
                 Use Formulary File 
               
               
                   
                   
                 share tier level 
                 2 = Tier Level 2 
                 to get Tier data. 
               
               
                   
                   
                 associated with 
                 3 = Tier Level 3 
               
               
                   
                   
                 the drug 
                 4 = Tier Level 4 
               
               
                 UMR 
                 CHAR 
                 Utilization 
                 PA = Prior 
                 Use Formulary File 
               
               
                   
                   
                 Management 
                 Authorization 
                 to pull in UMR: 
               
               
                   
                   
                 Requirements 
                 QL = Quantity 
                 QL = Applies only 
               
               
                   
                   
                   
                 Limit 
                 to 1 
               
               
                   
                   
                   
                 ST = Step Therapy 
                 PA = Applies to 1, 
               
               
                   
                   
                   
                   
                 2, and 3 
               
               
                   
                   
                   
                   
                 ST = Applies to 2 
               
               
                   
                   
                   
                   
                 and 3 on ST Value 
               
               
                 Therapeutic Class 
                 CHAR 
                 Therapeutic class 
                 Antipsychotic 
                 Use Formulary File 
               
               
                   
                   
                 drugs fall in 
                 Agents 
                 to pull in: 
               
               
                   
                   
                   
                   
                 Therapeutic Class 
               
               
                   
                   
                   
                   
                 (AHFS) 
               
               
                 Language 
                 CHAR 
                 Language data is 
                 English 
               
               
                   
                   
                 in 
                 Spanish 
               
               
                 Abbreviated Drug 
                 CHAR 
                 Drug Guide 
                 A = Abbreviated 
                 Use FRF to 
               
               
                 Guide 
                   
                 Indicator 
                 C = 
                 reference PDG 
               
               
                   
                   
                   
                 Comprehensive 
                 Indicator 
               
               
                   
               
             
          
         
       
     
         [0000]    
       
         
               
             
               
               
               
             
           
               
                 APPENDIX 1.9 
               
             
             
               
                   
               
               
                 Example of FDB Reports 
               
             
          
           
               
                 FDB Report Name 
                 This report tracks . . . 
                 List of Fields on this Report 
               
               
                   
               
               
                 Argus GPI Change 
                 Generic Product Identifier 
                 GCN 
               
               
                 Report 
                 changes on the Argus 
                 NDC 
               
               
                   
                 GPI override file. CF 
                 Label Name 
               
               
                   
                 automatically imports the 
                 Old GPI 
               
               
                   
                 Argus GPI override file weekly. 
                 New GPI 
               
               
                 Deleted NDC Report 
                 NDCs not part of the active drug 
               
               
                   
                 universe- 
               
               
                   
                 NDCs removed from the 
               
               
                   
                 formulary. 
               
               
                 GI Change Report 
                 New Generic Indicators listed for 
                 GCN 
               
               
                   
                 NDCs on the 
                 NDC 
               
               
                   
                 FDB NDDF. 
                 Label Name 
               
               
                   
                   
                 Old GI 
               
               
                   
                   
                 New GI 
               
               
                 Max Dose Change Report 
                 Changes to Adult Max Daily 
                 GCN 
               
               
                   
                 Dose for an NDC on the FDB 
                 NDC 
               
               
                   
                 NDDF 
                 Label name 
               
               
                   
                   
                 Old Adult Max Daily Dose 
               
               
                   
                   
                 Old Adult Max Daily Dosage 
               
               
                   
                   
                 Form 
               
               
                   
                   
                 Old Adult Max Daily Unit Quantity 
               
               
                   
                   
                 Old Adult Max Daily Unit Size 
               
               
                   
                   
                 New Adult Max Daily Dose 
               
               
                   
                   
                 New Adult Max Daily Dosage 
               
               
                   
                   
                 Form 
               
               
                   
                   
                 New Adult Max Daily Unit 
               
               
                   
                   
                 Quantity 
               
               
                   
                   
                 New Adult Max Daily Unit Size 
               
               
                 New GCN Report 
                 New GCNs added to the FDB 
                 GCN 
               
               
                   
                 NDDF. 
                 NDC 
               
               
                   
                   
                 Label name 
               
               
                   
                   
                 MFG ID 
               
               
                   
                   
                 GI 
               
               
                   
                   
                 GPI 
               
               
                   
                   
                 Route 
               
               
                   
                   
                 Dosage 
               
               
                 New NDC Report 
                 New NDCs added to the FDB 
                 GCN 
               
               
                   
                 NDDF, which are 
                 NDC 
               
               
                   
                 not assigned to a related 
                 Label Name 
               
               
                   
                 GCN/MedID. 
                 GI 
               
               
                   
                   
                 GPI 
               
               
                 New STC Report 
                 New STCs added to the FDB 
                 STC Code 
               
               
                   
                 NDDF 
                 STC Description 
               
               
                 Price Change Report 
                 WAC price changes by NDC on 
               
               
                   
                 the FDB NDDF. 
               
               
                 Reclassification 
                 FDB changes is made- 
                 New GCN 
               
               
                 Report 
                 regardless of any change 
                 Old GCN 
               
               
                   
                 in CF. 
                 NDC 
               
               
                   
                 Examples: 
                 Old STC 
               
               
                   
                 NDCs reclassified into a new 
                 New STC 
               
               
                   
                 GCN on the FDB 
                 Label Name 
               
               
                   
                 NDDF. 
                 GI 
               
               
                   
                 NDC was in GCN 12345 is now 
                 GPI 
               
               
                   
                 in GCN 12346. 
               
               
                   
               
             
          
         
       
     
         [0000]    
       
         
               
             
               
               
               
               
               
             
           
               
                 APPENDIX 2.0 
               
             
             
               
                   
               
               
                 Example of Formulary File Format and Fields 
               
             
          
           
               
                   
                   
                 Max. 
                   
                   
               
               
                 Field Name 
                 Field Type 
                 Length 
                 Description 
                 Sample Value(s) 
               
               
                   
               
               
                 RXCUI 
                 NUMBER required 
                 8 Max 
                 RxNorm concept unique 
                 210597 
               
               
                   
                   
                   
                 identifier from the active 
               
               
                   
                   
                   
                 Formulary Reference File. 
               
               
                 Tier 
                 CHAR Required 
                 2 
                 Defines the Cost Share Tier 
                 1 = Tier Level 1 
               
               
                   
                   
                   
                 Level Associated with the 
                 2 = Tier Level 2 
               
               
                   
                   
                   
                 drug. 
                 3 = Tier Level 3 
               
               
                   
                   
                   
                 Note: Assumes each drug 
                 4 = Tier Level 4 
               
               
                   
                   
                   
                 is assigned to only one tier 
                 5 = Tier Level 5 
               
               
                   
                   
                   
                 value. 
                 6 = Tier Level 6 
               
               
                 Drug Type 
                 CHAR Required 
                 1 
                 Indicates the drug&#39;s type 
                 1 = Generic 
               
               
                 Label 
                   
                   
                 label. 
                 2 = Preferred 
               
               
                   
                   
                   
                   
                 Generic 
               
               
                   
                   
                   
                   
                 3 = Non-Preferred 
               
               
                   
                   
                   
                   
                 Generic 
               
               
                   
                   
                   
                   
                 4 = Brand 
               
               
                   
                   
                   
                   
                 5 = Preferred Brand 
               
               
                   
                   
                   
                   
                 6 = Non-Preferred 
               
               
                   
                   
                   
                   
                 Brand 
               
               
                 Quantity Limits 
                 CHAR Required 
                 1 
                 Does the drug have a 
                 0 = No Quantity 
               
               
                   
                   
                   
                 quantity limit restriction? 
                 Limits 
               
               
                   
                   
                   
                   
                 1 = Quantity Limits 
               
               
                   
                   
                   
                   
                 Apply 
               
               
                 Quantity Limit 
                 NUM Sometimes 
                 7 
                 If the Quantity Limit is 1, 
                 9.99999 grams 
               
               
                 Amount 
                 Required 
                   
                 type the quantity limit unit 
               
               
                   
                   
                   
                 amount for a given Rx or 
               
               
                   
                   
                   
                 time period. These units 
               
               
                   
                   
                   
                 must be defined by a unit of 
               
               
                   
                   
                   
                 measure such as: number 
               
               
                   
                   
                   
                 of tablets, milliliters, grams 
               
               
                   
                   
                   
                 and so on. 
               
               
                   
                   
                   
                 If the Quantity Limit is 0, 
               
               
                   
                   
                   
                 this field is blank. 
               
               
                   
                   
                   
                 The maximum number of 
               
               
                   
                   
                   
                 decimal points accepted is 
               
               
                   
                   
                   
                 5. 
               
               
                 Quantity Limit 
                 NUM Sometimes 
                 3 
                 The number of days 
                 9 tablets every 60 
               
               
                 Days 
                 required 
                   
                 associated with the quantity 
                 days 
               
               
                   
                   
                   
                 limit. The maximum 
               
               
                   
                   
                   
                 number accepted is 999. 
               
               
                   
                   
                   
                 Exception: If the Quantity 
               
               
                   
                   
                   
                 Limit field is 0, leave this 
               
               
                   
                   
                   
                 field blank. 
               
               
                 Prior 
                 CHAR Required 
                 1 
                 Is prior authorization 
                 0 = No Prior 
               
               
                 Authorization 
                   
                   
                 required for the drug? 
                 Authorization 
               
               
                 Type 
                   
                   
                   
                 1 = Prior 
               
               
                   
                   
                   
                   
                 Authorization 
               
               
                   
                   
                   
                   
                 2 = Prior 
               
               
                   
                   
                   
                   
                 Authorization 
               
               
                   
                   
                   
                   
                 Applies to New 
               
               
                   
                   
                   
                   
                 Starts Only 
               
               
                   
                   
                   
                   
                 3 = Part B vs. Part 
               
               
                   
                   
                   
                   
                 D Prior 
               
               
                   
                   
                   
                   
                 Authorization Only 
               
               
                 Prior 
                 CHAR Sometimes 
                 100 
                 Description of the drug&#39;s 
                 Antiemetics 
               
               
                 Authorization 
                 Required 
                   
                 prior authorization group as 
               
               
                 Group Desc 
                   
                   
                 it will appear on the 
               
               
                   
                   
                   
                 submitted prior 
               
               
                   
                   
                   
                 authorization attachment. 
               
               
                   
                   
                   
                 The group name may 
               
               
                   
                   
                   
                 represent a drug category, 
               
               
                   
                   
                   
                 class, or (if no other 
               
               
                   
                   
                   
                 grouping structure applies) 
               
               
                   
                   
                   
                 may simply be the name o 
               
               
                   
                   
                   
                 the drug. 
               
               
                   
                   
                   
                 Exception: if response to 
               
               
                   
                   
                   
                 Prior Authorization Type is 
               
               
                   
                   
                   
                 0 or 3, then leave this field 
               
               
                   
                   
                   
                 blank. 
               
               
                 Limited 
                 CHAR Required 
                 1 
                 Is access to this drug 
                 1 = yes 
               
               
                 Access? 
                   
                   
                 limited to certain 
                 0 = No 
               
               
                   
                   
                   
                 pharmacies? 
               
               
                 Therapeutic 
                 CHAR Required 
                 100 
                 Enter the name of the 
                 Analgesics 
               
               
                 Category Name 
                   
                   
                 category for the drug. 
               
               
                 Therapeutic 
                 CHAR Required 
                 100 
                 Enter the name of the class 
                 Opioid Analgesics 
               
               
                 Class Name 
                   
                   
                 for the drug. 
               
               
                 Step Therapy 
                 CHAR Required 
                 1 
                 Does step therapy apply to 
                 0 = Not Part of a 
               
               
                 Type 
                   
                   
                 this drug? 
                 Step Therapy 
               
               
                   
                   
                   
                 Note: Prerequisite (Step 1) 
                 Program 
               
               
                   
                   
                   
                 drugs should also have a 
                 1 = Step Therapy 
               
               
                   
                   
                   
                 value of 1 in this field. 
                 Applies 
               
               
                   
                   
                   
                   
                 2 = Step Therapy 
               
               
                   
                   
                   
                   
                 Applies to New 
               
               
                   
                   
                   
                   
                 Starts 
               
               
                 Step Therapy 
                 NUM Sometimes 
                 2 
                 The total number of step 
                 3 
               
               
                 Total Groups 
                 Required 
                   
                 therapy drug-treatment 
               
               
                   
                   
                   
                 groups in which the drug is 
               
               
                   
                   
                   
                 included. The maximum 
               
               
                   
                   
                   
                 number accepted is 99. 
               
               
                   
                   
                   
                 If the Step therapy Type is 
               
               
                   
                   
                   
                 0, then this field is blank. 
               
               
                   
                   
                   
                 Note: the last two fields 
               
               
                   
                   
                   
                 should be repeated in the 
               
               
                   
                   
                   
                 record - based on the value 
               
               
                   
                   
                   
                 in the Step Therapy Total 
               
               
                   
                   
                   
                 Groups field. 
               
               
                 Step Therapy 
                 CHAR Sometimes 
                 100 
                 Description of the step 
                 CHF Therapy 
               
               
                 Group Desc 
                 Required 
                   
                 therapy drug treatment 
                 Angina Therapy 
               
               
                   
                   
                   
                 group. 
                 CVD Therapy 
               
               
                   
                   
                   
                 If the Step Therapy Type is 
               
               
                   
                   
                   
                 0, this field should be blank. 
               
               
                   
                   
                   
                 Note: For a given RXCUI, 
               
               
                   
                   
                   
                 each ST Group Description 
               
               
                   
                   
                   
                 must be unique 
               
               
                 Step Therapy 
                 NUM Sometimes 
                 2 
                 Identifies the step number 
                 4 
               
               
                 Step Value 
                 Required 
                   
                 or level within the sequence 
                 Example 
               
               
                   
                   
                   
                 for the Step Therapy 
                 Step 4 of 6 
               
               
                   
                   
                   
                 Group. The range of 
               
               
                   
                   
                   
                 accepted values is 1 to 99. 
               
               
                   
                   
                   
                 This field is repeated in the 
                 1 
               
               
                   
                   
                   
                 record (based on the 
                 Example 
               
               
                   
                   
                   
                 numerical value in the Step 
                 Step 1 of 3 
               
               
                   
                   
                   
                 Therapy Total Groups field) 
               
               
                   
                   
                   
                 and in the same order as 
               
               
                   
                   
                   
                 the list of values given for 
               
               
                   
                   
                   
                 the Step Therapy Group 
               
               
                   
                   
                   
                 Desc field. 
               
               
                   
                   
                   
                 If the Step Therapy Type is 
                 5 
               
               
                   
                   
                   
                 0, this field is blank. 
                 Example 
               
               
                   
                   
                   
                   
                 Step 5 of 5 
               
               
                   
               
             
          
         
       
     
         [0000]    
       
         
               
             
               
               
               
               
             
               
               
               
               
             
           
               
                 APPENDIX 2.1 
               
             
             
               
                   
               
               
                 Example of Fields for PA Group File 
               
             
          
           
               
                   
                   
                 Max. 
                   
               
               
                 Field Name 
                 Field Type 
                 Length 
                 Description 
               
               
                   
               
             
          
           
               
                 PA Group Desc 
                 CHAR Required 
                 100 
                 Describes the prior authorization group-as it appears 
               
               
                   
                   
                   
                 on the submitted formulary file. This field must exactly 
               
               
                   
                   
                   
                 match the value in the Prior Authorization Group Desc 
               
               
                   
                   
                   
                 field in the CF-generated and submitted formulary file. 
               
               
                 PA Criteria 
                 CHAR Required 
                 1 (0 or 1) 
                 0 = The PA criteria content did not change for this 
               
               
                 Change 
                   
                   
                 group description, compared to CY 2009. 1 = The 
               
               
                 Indicator 
                   
                   
                 description is new or the criteria content changed (for 
               
               
                   
                   
                   
                 example, additional restrictions). 
               
               
                 Covered Uses 
                 CHAR Required 
                 3000 
                 Includes the FDA-approved and off-label indications 
               
               
                   
                   
                   
                 for which the drug(s) will be covered. At a minimum, 
               
               
                   
                   
                   
                 “All FDA-approved indications not otherwise excluded 
               
               
                   
                   
                   
                 from Part D.” If the PA will be approved for all non- 
               
               
                   
                   
                   
                 excluded off-label uses, in addition to the labeled 
               
               
                   
                   
                   
                 indications, “All medically accepted indications not 
               
               
                   
                   
                   
                 otherwise excluded from Part D” is included. If only 
               
               
                   
                   
                   
                 certain off-label uses will be approved by prior 
               
               
                   
                   
                   
                 authorization, the specific uses will be listed following 
               
               
                   
                   
                   
                 this statement: “All FDA-approved indications not 
               
               
                   
                   
                   
                 otherwise excluded from Part D”. 
               
               
                 Exclusion 
                 CHAR If 
                 2000 
                 Describes any criteria, for example, co morbid 
               
               
                 Criteria 
                 applicable 
                   
                 diseases, laboratory data and so on, which will result 
               
               
                   
                   
                   
                 in the exclusion of coverage for a member. 
               
               
                 Required 
                 CHAR 
                 2000 
                 Laboratory, diagnostic, or other medical information 
               
               
                 Medical 
                 If applicable 
                   
                 required for initiation or continuation of the drug(s). 
               
               
                 Information 
               
               
                 Age 
                 CHAR 
                 500 
                 Age limitations or restrictions required for prior 
               
               
                 Restrictions 
                 If applicable 
                   
                 authorization approval. 
               
               
                 Prescriber 
                 CHAR 
                 500 
                 Describes the prescriber attribute/s necessary for a 
               
               
                 Restrictions 
                 If applicable 
                   
                 PA to be 
               
               
                   
                   
                   
                 considered. 
               
               
                   
                   
                   
                 Examples 
               
               
                   
                   
                   
                 Specialist in a field 
               
               
                   
                   
                   
                 Registered under a certain program 
               
               
                 Coverage 
                 CHAR 
                 100 
                 Duration for which the prior authorization will be 
               
               
                 Duration 
                 Required 
                   
                 approved. 
               
               
                 Other Criteria 
                 CHAR 
                 3000 
                 Describes any other relevant criteria that cannot be 
               
               
                   
                 If applicable 
                   
                 otherwise classified into another field. 
               
               
                   
               
             
          
         
       
     
         [0000]    
       
         
               
             
               
               
               
               
             
               
               
               
               
             
           
               
                 APPENDIX 2.2 
               
             
             
               
                   
               
               
                 Example of Data Fields for ST Files 
               
             
          
           
               
                   
                   
                 Maxi- 
                   
               
               
                 Field 
                   
                 mum 
               
               
                 Name 
                 Field Type 
                 Length 
                 Description 
               
               
                   
               
             
          
           
               
                 Step 
                 CHAR 
                 100 
                 Describes the step therapy group as it 
               
               
                 Therapy 
                 Always 
                   
                 appears on the submitted formulary 
               
               
                 Group 
                 Required 
                   
                 file. This field must be an exact match 
               
               
                 Desc 
                   
                   
                 of the value entered in the Step 
               
               
                   
                   
                   
                 Therapy Group Desc field on the CF- 
               
               
                   
                   
                   
                 generated and submitted formulary file. 
               
               
                   
                   
                   
                 Note: For each Step Therapy Group 
               
               
                   
                   
                   
                 Description, there must be an RxCUI 
               
               
                   
                   
                   
                 with a Step Therapy Value equal to 1. 
               
               
                 Step 
                 CHAR 
                 4000 
                 Describes the criteria of the step 
               
               
                 Therapy  
                 Always 
                   
                 therapy drug. 
               
               
                 Criteria 
                 Required 
               
               
                   
               
             
          
         
       
     
       Appendix 2.3 
     Example of Logic for Maintaining Active Drug Formularies 
       [0086]    The system may assign values to new NDCs based on these rules:
       If all values of all NDCs in a GCN match, assign a new NDC to the related GCN.   If all values of all NDCs in a GCN do not match, but all values in the MedID do match, assign a new NDC to the related MedID.   If all values of any NDCs in a GCN or MedID do not match, do not assign a new NDC to the related GCN.   For any NDC that does not fall into one of the previous rules (such as new GCNs), set each NDC as Not Covered—with no other coverage values. The system places these NDCs into Pending status. Using First Data Bank (FDB) reports, a user can search each GCN/NDC and edit them manually.       
 
         [0091]    When a formulary&#39;s status is changed from Inactive to Active, the system uses these rules to determine values for NDC records. The system will automatically remove NDCs that are:
       No longer on the First Data Bank (FDB) NDDF (file from FDB)   Have become a repackaged drug   Have become obsolete   Have switched to an OTC indication (non-diabetes related)       
 
         [0096]    The system maintains Generic Product Identifier (GPI) values using the following sequentially-applied rules. Once an NDC meets a rule, the system assigns the GIP value and that NDC is excluded from subsequent rules—except for the final step, which is an override to the previous steps.
       a. If GNI (Generic Name Indicator)=0 (non-drug item), then GPI=0   b. If GNI=1 (generically-named) or Generic name=Brand Name, then GPI=1   c. If GNI=2 (brand-named) AND INNOV=1 (innovator), then GPI=2   d. If NDA (new drug application)=Y (yes), then GPI=2   e. If ANDA (abbreviated new drug application)=Y (yes), then GPI=1   f. If INNOV=0 (non-innovator) and repackage indicator=0 (non-repackager), then GPI=1   g. If INNOV=0 (non-innovator) and repackager indicator=1 (re-packager), then GPI=2   h. If an NDC is on the Argus GPI Override file, then that NDC is assigned to the GPI listed on that file.       
 
         [0000]    
       
         
               
             
               
               
             
           
               
                 APPENDIX 2.4 
               
             
             
               
                   
               
               
                 Example of Data Elements and Rules for Context Drug List Web File 
               
             
          
           
               
                 Data Element 
                 Rule 
               
               
                   
               
               
                 MedID 
                 Populated from First Data Bank. 
               
               
                 Formulary ID 
                 Populated from CF&#39;s Formulary ID. 
               
               
                 Informational 
                 Populated from informational context drug lists loaded and attached to the drug&#39;s 
               
               
                 Type 
                 Formulary. 
               
               
                 B vs. D 
                 If this drug is searched, the Medicare Drug List Search, Provider Drug List Search, 
               
               
                   
                 Medicare Enrollment Rx Calculator, and Medicare MyHumana Rx Calculator all 
               
               
                   
                 return coverage labeled Part B vs. Part D Determination may be required. 
               
               
                 Maintenance 
                 If the plan selected has coverage, the Medicare Drug List Search and Medicare Rx 
               
               
                   
                 Calculator display the drug-and price, if appropriate-with Maintenance coverage 
               
               
                   
                 in the gap. 
               
               
                 Home Infusion 
                 If the plan selected has coverage, the Medicare Drug List Search and Medicare Rx 
               
               
                   
                 Calculator display the drug-and price, if appropriate-with Home Infusion coverage 
               
               
                   
                 in the gap. 
               
               
                 ED 
                 If the plan selected has coverage, the Medicare Drug List Search and Medicare Rx 
               
               
                   
                 Calculator display the drug-and price, if appropriate-with Enhanced Alternative 
               
               
                   
                 coverage. 
               
               
                 Benzo 
                 If the plan selected has coverage, the Medicare Drug List Search and Medicare Rx 
               
               
                   
                 Calculator will display the drug-and price, if appropriate-with Enhanced 
               
               
                   
                 Alternative coverage. 
               
               
                 Barb 
                 If the plan selected has coverage, the Medicare Drug List Search and Medicare Rx 
               
               
                   
                 Calculator display the drug-and price, if appropriate-with Enhanced Alternative 
               
               
                   
                 coverage. 
               
               
                 Part B only 
                 The Medicare Drug List Search and Medicare Rx Calculator display the drug-and 
               
               
                   
                 price, if appropriate-with Covered Under Part B. 
               
               
                 SpecialtyRx 
                 Drug Pricing, Medicare/Commercial Drug List Search, and Provider Drug List 
               
               
                   
                 Search display specialty options corresponding to each application for this drug and 
               
               
                   
                 formulary. 
               
               
                   
               
             
          
         
       
     
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                 APPENDIX 2.5 
               
             
             
               
                   
               
               
                 Example of Data Elements and Rules for Formulary Information Web File 
               
             
          
           
               
                 Data Element 
                 Rule 
               
               
                   
               
               
                 MedID 
                 Populated from First Data Bank. 
               
               
                 Formulary ID 
                 Populated from CF&#39;s Formulary ID. 
               
               
                 Version # 
                 Populated from latest approved HPMS Submission file corresponding to the 
               
               
                   
                 Formulary ID. 
               
               
                 Coverage 
                 If the formulary is Medicare and drug is on the latest approved HPMS 
               
               
                   
                 Submission file, then populates from the latest approved HPMS Submission file. 
               
               
                   
                 Otherwise populates from the latest Formulary Ops Approved value for this drug 
               
               
                   
                 and formulary in CF. 
               
               
                   
                 If the formulary is commercial, populates from the latest Formulary Ops 
               
               
                   
                 Approved value for this drug and formulary in CF. 
               
               
                 Tier 
                 Same rules as Coverage. 
               
               
                 Prior Authorization 
                 Same rules as Coverage. 
               
               
                 Y/N 
               
               
                 Step Therapy 
                 Populates from the latest Formulary Ops Approved value for this drug and 
               
               
                 Prerequisite Y/N 
                 formulary in CF. 
               
               
                 Step Therapy Safety 
                 Same rules as Step Therapy Prerequisite Y/N 
               
               
                 Edit Y/N 
               
               
                 Quantity Limit Y/N 
                 Same rules as Coverage. 
               
               
                 Quantity Limit Unit 
                 Same rules as Step Therapy Prerequisite Y/N 
               
               
                 of Measure 
               
               
                 Quantity Limit Days 
                 Same rules as Coverage. 
               
               
                 Supply 
               
               
                 Quantity Limit 
                 Same rules as Coverage. 
               
               
                 Amount 
               
               
                 Age Min 
                 Same rules as Step Therapy Prerequisite Y/N 
               
               
                 Age Max. 
                 Same rules as Step Therapy Prerequisite Y/N 
               
               
                 Gender 
                 Same rules as Step Therapy Prerequisite Y/N 
               
               
                 GPI 
                 Same rules as Step Therapy Prerequisite Y/N 
               
               
                   
               
             
          
         
       
     
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                 APPENDIX 2.6 
               
             
             
               
                   
               
               
                 Example of Data Elements and Rules for Drug Information Web File 
               
             
          
           
               
                 Data Element 
                 Rule 
               
               
                   
               
               
                 MedID 
                 Populates from First Data Bank 
               
               
                 Drug Description 
                 Populates from First Data Bank 
               
               
                 GCN 
                 Populates from First Data Bank 
               
               
                 Claim Count 
                 Populates from the Argus ODL file 
               
               
                 Drug Dose and 
                 Populates from First Data Bank 
               
               
                 Form 
               
               
                 Dosage 
                 Populates from First Data Bank 
               
               
                 Form 
                 Populates from First Data Bank 
               
               
                 Route 
                 Populates from First Data Bank 
               
               
                 Retail Price per 
                 Uses the Pricing NDC stored for both Web and Plan Finder. If the Pricing NDC 
               
               
                 Unit 
                 does not have a WAC then: 
               
               
                   
                 If the drug is a generic, calculates the average generic price for all NDCs in the 
               
               
                   
                 GCN. Note: WAC values that are 0 or Null are not included in the calculation of the 
               
               
                   
                 average. 
               
               
                   
                 If there is no average generic price-because no NDCs within the GCN have a 
               
               
                   
                 WAC price-then CF takes the AWP for the NDC and multiplies by 49%. 
               
               
                   
                 If the drug is a brand, then CF takes the AWP for the NDC and multiplies by 84%. 
               
               
                 MAC Price 
                 Populates from the MAC file in the CMS Plan Finder Automation Application. 
               
               
                 Pricing Unit of 
                 Populates from First Data Bank 
               
               
                 Measure 
               
               
                 Common Quantity 
                 Populates from the Argus ODL file 
               
               
                 Common Days 
                 Populates from the Argus ODL file 
               
               
                 Supply 
               
               
                 Mail Price per Unit 
                 Populates in the following manner: 
               
               
                   
                 If the drug is on the RightSourceRx Target Drug List, uses the AWP which is 19% 
               
               
                   
                 of the RightSourceRx Target Drug List NDC. 
               
               
                   
                 If the drug is not on the RightSourceRx Target Drug List, then uses the WAC price 
               
               
                   
                 of the NDC, and pushes to both the Plan Finder and the Web: 
               
               
                   
                 If the Pricing NDC does not have a WAC then: 
               
               
                   
                    If the drug is a generic, calculates the average generic price for all NDCs 
               
               
                   
                    in the GCN-making sure WAC values 0 or Null are not included in the 
               
               
                   
                    calculation of the average. 
               
               
                   
                    If there is no average generic price-because no NDCs within the GCN 
               
               
                   
                    have a WAC price-takes the AWP for the NDC and multiplies by 49%. 
               
               
                   
                    If the drug is a brand, then takes the AWP for the NDC and multiplies by 
               
               
                   
                    84%. 
               
               
                   
               
             
          
         
       
     
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                 APPENDIX 2.7 
               
             
             
               
                   
               
               
                 Example of Data Elements and Rules for Alternative Logic Web File 
               
             
          
           
               
                 Data Element 
                 Rule 
               
               
                   
               
               
                 MedID 
                 Populates from First Data Bank. 
               
               
                 Formulary ID 
                 Populates from CF&#39;s Formulary ID. 
               
               
                 Alternative 
                 Populates from First Data Bank-using this logic: 
               
               
                 MedID 
                 Populates from alternative MedID in the MedID&#39;s ultimate child; 
               
               
                   
                 however, if there are no alternative MedIDs in the MedID&#39;s ultimate 
               
               
                   
                 child, then goes up one level and returns alternative MedIDs based 
               
               
                   
                 on that ETC. 
               
               
                   
                 Note: Accounts for overrides and changes made using CF&#39;s 
               
               
                   
                 Override Alternatives page. 
               
               
                 Coverage 
                 If the formulary is Medicare, and the drug is on the latest approved 
               
               
                 Status of 
                 HPMS 
               
               
                 Alternative 
                 Submission file, populates from the latest approved HPMS 
               
               
                 Drug 
                 Submission file. 
               
               
                   
                 Otherwise, populates from the latest Formulary Ops Approved 
               
               
                   
                 value for this drug and formulary in CF. 
               
               
                   
                 If the formulary is commercial, populates from the latest Formulary 
               
               
                   
                 Ops Approved value for this drug and formulary in CF. 
               
               
                   
               
             
          
         
       
     
       Appendix 2.8 
     Example of Rules for Condition Web File 
       [0105]    A Condition Search has these rules:
       The search uses the ETC level that corresponds to the current level of specificity.   Only formulary data for drugs with Formulary Ops Approved status, for active Medicare and Commercial formularies, is extracted.   If there are multiple records for a particular MedID (and this is not a Medicare HPMS Proxy File drug) then the strictest record appears—Maximum Tier, PA, QL, or Step Therapy.