Spreadsheet: 714482d1611243400-display-range-based-on-multiple-cell-values-test-cases-templates-sandbox2
Sheet: Copays

3 tier / Excl Accredo = N
Test Case Name/Description | Expected Results | Actual Results/Comments | Tester | Test Date | Status | Test Pharmacy NPI | Test Member ID
Product: LIPITOR 10mg NDC: [PHONE] Qty/Days: 30/30 at RETAIL | Claim pays at retail tier 3 |  |  |  | No Run | 1215036512
Product: HUMALOG 100/ml NDC: [PHONE] Qty/Days: 30/30 at RETAIL | Claim pays at retail tier 2 |  |  |  | No Run | 1215036512
Product: SIMVASTATIN 10mg NDC: [PHONE] Qty/Days: 30/30 at RETAIL | Claim pays at retail tier 1 |  |  |  | No Run | 1215036512
Product: HUMALOG 100/ml NDC: [PHONE] Qty/Days: 60/60 at RETAIL | Claim pays at 2 x retail tier 2 |  |  |  | No Run | 1215036512
Product: HUMALOG 100/ml NDC: [PHONE] Qty/Days: 90/90 at RETAIL | Claim returns reject 7X=DAYS SUPPLY EXCEEDS PLAN LIMITATION -or- Claim pays at mail tier 2 (Smart90) |  |  |  | No Run | 1215036512
Product: LIPITOR 10mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | Claim pays at mail tier 3 |  |  |  | No Run | 1558443911
Product: HUMALOG 100/ml NDC: [PHONE] Qty/Days: 90/90 at MAIL | Claim pays at mail tier 2 |  |  |  | No Run | 1558443911
Product: SIMVASTATIN 10mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | Claim pays at mail tier 1 |  |  |  | No Run | 1558443911
3 tier / Excl Accredo = Y
Test Case Name/Description | Expected Results | Actual Results/Comments | Tester | Test Date | Status | Test Pharmacy NPI | Test Member ID
Product: LIPITOR 10mg NDC: [PHONE] Qty/Days: 30/30 at RETAIL | Claim pays at retail tier 3 |  |  |  | No Run | 1215036512
Product: HUMALOG 100/ml NDC: [PHONE] Qty/Days: 30/30 at RETAIL | Claim pays at retail tier 2 |  |  |  | No Run | 1215036512
Product: SIMVASTATIN 10mg NDC: [PHONE] Qty/Days: 30/30 at RETAIL | Claim pays at retail tier 1 |  |  |  | No Run | 1215036512
Product: HUMALOG 100/ml NDC: [PHONE] Qty/Days: 60/60 at RETAIL | Claim pays at 2 x retail tier 2 |  |  |  | No Run | 1215036512
Product: HUMALOG 100/ml NDC: [PHONE] Qty/Days: 90/90 at RETAIL | Claim returns reject 7X=DAYS SUPPLY EXCEEDS PLAN LIMITATION -or- Claim pays at mail tier 2 (Smart90) |  |  |  | No Run | 1215036512
Product: LIPITOR 10mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | Claim pays at mail tier 3 |  |  |  | No Run | 1558443911
Product: HUMALOG 100/ml NDC: [PHONE] Qty/Days: 90/90 at MAIL | Claim pays at mail tier 2 |  |  |  | No Run | 1558443911
Product: SIMVASTATIN 10mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | Claim pays at mail tier 1 |  |  |  | No Run | 1558443911
Product: AUBAGIO 14mg NDC: [PHONE] Qty/Days: 30/30 at ACCREDO SPECIALTY | Claim pays at retail tier 3 |  |  |  | No Run | 1851346522
Product: GRANIX 300mcg/ml NDC: [PHONE] Qty/Days: 1/30 at ACCREDO SPECIALTY | Claim pays at retail tier 2 |  |  |  | No Run | 1851346522
Product: CALCIUM FOLINATE NDC: [PHONE] Qty/Days: 1/30 at CAREMARK SPECIALTY | Claim returns reject 70=PRODUCT/SERVICE NOT COVERED. After override, claim returns reject 4W = MUST DISPENSE THROUGH SPECIALTY PHARMACY |  |  |  | No Run | 1902887805
Product: VIGABATRIN 500mg NDC: [PHONE] Qty/Days: 30/30 at CAREMARK SPECIALTY | Claim returns reject 4W = MUST DISPENSE THROUGH SPECIALTY PHARMACY |  |  |  | No Run | 1902887805
3 tier / Excl Accredo = N / VBID Mail
Test Case Name/Description | Expected Results | Actual Results/Comments | Tester | Test Date | Status | Test Pharmacy NPI | Test Member ID
Product: LIPITOR 10mg NDC: [PHONE] Qty/Days: 30/30 at RETAIL | Claim pays at retail tier 3 |  |  |  | No Run | 1215036512
Product: HUMALOG 100/ml NDC: [PHONE] Qty/Days: 30/30 at RETAIL | Claim pays at retail tier 2 |  |  |  | No Run | 1215036512
Product: SIMVASTATIN 10mg NDC: [PHONE] Qty/Days: 30/30 at RETAIL | Claim pays at retail tier 1 |  |  |  | No Run | 1215036512
Product: HUMALOG 100/ml NDC: [PHONE] Qty/Days: 60/60 at RETAIL | Claim pays at 2 x retail tier 2 |  |  |  | No Run | 1215036512
Product: HUMALOG 100/ml NDC: [PHONE] Qty/Days: 90/90 at RETAIL | Claim returns reject 7X=DAYS SUPPLY EXCEEDS PLAN LIMITATION -or- Claim pays at VBID mail tier 2 (Smart90) |  |  |  | No Run | 1215036512
Product: LIPITOR 10mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | Claim pays at mail tier 3 |  |  |  | No Run | 1558443911
Product: HUMALOG 100/ml NDC: [PHONE] Qty/Days: 90/90 at MAIL | Claim pays at VBID mail tier 2 |  |  |  | No Run | 1558443911
Product: SIMVASTATIN 10mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | Claim pays at VBID mail tier 1 |  |  |  | No Run | 1558443911
Product: FARXIGA 10mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | Claim pays at VBID mail tier 2 |  |  |  | No Run | 1558443911
Product: FARXIGA 5mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | Claim pays at VBID mail tier 2 |  |  |  | No Run | 1558443911
Product: XIGDUO XR 10-1000mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | Claim pays at VBID mail tier 2 |  |  |  | No Run | 1558443911
Product: XIGDUO XR 10mg-500mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | Claim pays at VBID mail tier 2 |  |  |  | No Run | 1558443911
Product: XIGDUO XR 2.5-1000mg NDC: [PHONE] Qty/Days: 60/90 at MAIL | Claim pays at VBID mail tier 2 |  |  |  | No Run | 1558443911
Product: XIGDUO XR 5mg-500mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | Claim pays at VBID mail tier 2 |  |  |  | No Run | 1558443911
Product: XIGDUO XR 5mg-1000mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | Claim pays at VBID mail tier 2 |  |  |  | No Run | 1558443911
Product: INVOKAMET 150-1000mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | After transition fill, claim returns reject MR=DRUG NOT ON FORMULARY. Created PA and claim pays at mail tier 3. |  |  |  | No Run | 1558443911
Product: INVOKAMET 150-500mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | After transition fill, claim returns reject MR=DRUG NOT ON FORMULARY. Created PA and claim pays at mail tier 3. |  |  |  | No Run | 1558443911
Product: INVOKAMET 50-1000mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | After transition fill, claim returns reject MR=DRUG NOT ON FORMULARY. Created PA and claim pays at mail tier 3. |  |  |  | No Run | 1558443911
Product: INVOKAMET 50mg-500mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | After transition fill, claim returns reject MR=DRUG NOT ON FORMULARY. Created PA and claim pays at mail tier 3. |  |  |  | No Run | 1558443911
Product: INVOKAMET XR 150-1000mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | After transition fill, claim returns reject MR=DRUG NOT ON FORMULARY. Created PA and claim pays at mail tier 3. |  |  |  | No Run | 1558443911
Product: INVOKAMET XR 150-500mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | After transition fill, claim returns reject MR=DRUG NOT ON FORMULARY. Created PA and claim pays at mail tier 3. |  |  |  | No Run | 1558443911
Product: INVOKAMET XR 50-1000mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | After transition fill, claim returns reject MR=DRUG NOT ON FORMULARY. Created PA and claim pays at mail tier 3. |  |  |  | No Run | 1558443911
Product: INVOKAMET XR 50mg-500mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | After transition fill, claim returns reject MR=DRUG NOT ON FORMULARY. Created PA and claim pays at mail tier 3. |  |  |  | No Run | 1558443911
Product: INVOKANA 100mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | After transition fill, claim returns reject MR=DRUG NOT ON FORMULARY. Created PA and claim pays at mail tier 3. |  |  |  | No Run | 1558443911
Product: INVOKANA 100mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | After transition fill, claim returns reject MR=DRUG NOT ON FORMULARY. Created PA and claim pays at mail tier 3. |  |  |  | No Run | 1558443911
Product: INVOKANA 300mg NDC: [PHONE]  Qty/Days: 90/90 at MAIL | After transition fill, claim returns reject MR=DRUG NOT ON FORMULARY. Created PA and claim pays at mail tier 3. |  |  |  | No Run | 1558443911
Product: INVOKANA  300mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | After transition fill, claim returns reject MR=DRUG NOT ON FORMULARY. Created PA and claim pays at mail tier 3. |  |  |  | No Run | 1558443911
4 tier / Excl Accredo = N
Test Case Name/Description | Expected Results | Actual Results/Comments | Tester | Test Date | Status | Test Pharmacy NPI | Test Member ID
Product: LIPITOR 10mg NDC: [PHONE] Qty/Days: 30/30 at RETAIL | Claim pays at retail tier 4 |  |  |  | No Run | 1215036512
Product: HUMALOG 100/ml NDC: [PHONE] Qty/Days: 30/30 at RETAIL | Claim pays at retail tier 3 |  |  |  | No Run | 1215036512
Product: SIMVASTATIN 10mg NDC: [PHONE] Qty/Days: 30/30 at RETAIL | Claim pays at retail tier 2 |  |  |  | No Run | 1215036512
Product: HUMALOG 100/ml NDC: [PHONE] Qty/Days: 60/60 at RETAIL | Claim pays at 2 x retail tier 3 |  |  |  | No Run | 1215036512
Product: HUMALOG 100/ml NDC: [PHONE] Qty/Days: 90/90 at RETAIL | Claim returns reject 7X=DAYS SUPPLY EXCEEDS PLAN LIMITATION -or- Claim pays at mail tier 3 (Smart90) |  |  |  | No Run | 1215036512
Product: LIPITOR 10mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | Claim pays at mail tier 4 |  |  |  | No Run | 1558443911
Product: HUMALOG 100/ml NDC: [PHONE] Qty/Days: 90/90 at MAIL | Claim pays at mail tier 3 |  |  |  | No Run | 1558443911
Product: SIMVASTATIN 10mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | Claim pays at mail tier 2 |  |  |  | No Run | 1558443911
4 tier / Excl Accredo = Y
Test Case Name/Description | Expected Results | Actual Results/Comments | Tester | Test Date | Status | Test Pharmacy NPI | Test Member ID
Product: LIPITOR 10mg NDC: [PHONE] Qty/Days: 30/30 at RETAIL | Claim pays at retail tier 4 |  |  |  | No Run | 1215036512
Product: HUMALOG 100/ml NDC: [PHONE] Qty/Days: 30/30 at RETAIL | Claim pays at retail tier 3 |  |  |  | No Run | 1215036512
Product: SIMVASTATIN 10mg NDC: [PHONE] Qty/Days: 30/30 at RETAIL | Claim pays at retail tier 2 |  |  |  | No Run | 1215036512
Product: HUMALOG 100/ml NDC: [PHONE] Qty/Days: 60/60 at RETAIL | Claim pays at 2 x retail tier 3 |  |  |  | No Run | 1215036512
Product: HUMALOG 100/ml NDC: [PHONE] Qty/Days: 90/90 at RETAIL | Claim returns reject 7X=DAYS SUPPLY EXCEEDS PLAN LIMITATION -or- Claim pays at mail tier 3 (Smart90) |  |  |  | No Run | 1215036512
Product: LIPITOR 10mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | Claim pays at mail tier 4 |  |  |  | No Run | 1558443911
Product: HUMALOG 100/ml NDC: [PHONE] Qty/Days: 90/90 at MAIL | Claim pays at mail tier 3 |  |  |  | No Run | 1558443911
Product: SIMVASTATIN 10mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | Claim pays at mail tier 2 |  |  |  | No Run | 1558443911
Product: AUBAGIO 14mg NDC: [PHONE] Qty/Days: 30/30 at ACCREDO SPECIALTY | Claim pays at retail tier 4 |  |  |  | No Run | 1851346522
Product: GRANIX 300mcg/ml NDC: [PHONE] Qty/Days: 1/30 at ACCREDO SPECIALTY | Claim pays at retail tier 3 |  |  |  | No Run | 1851346522
Product: CALCIUM FOLINATE NDC: [PHONE] Qty/Days: 1/30 at CAREMARK SPECIALTY | Claim returns reject 70=PRODUCT/SERVICE NOT COVERED. After override, claim returns reject 4W = MUST DISPENSE THROUGH SPECIALTY PHARMACY |  |  |  | No Run | 1902887805
Product: VIGABATRIN 500mg NDC: [PHONE] Qty/Days: 30/30 at CAREMARK SPECIALTY | Claim returns reject 4W = MUST DISPENSE THROUGH SPECIALTY PHARMACY |  |  |  | No Run | 1902887805
4 tier / Excl Accredo = N / VBID Mail
Test Case Name/Description | Expected Results | Actual Results/Comments | Tester | Test Date | Status | Test Pharmacy NPI | Test Member ID
Product: LIPITOR 10mg NDC: [PHONE] Qty/Days: 30/30 at RETAIL | Claim pays at retail tier 4 |  |  |  | No Run | 1215036512
Product: HUMALOG 100/ml NDC: [PHONE] Qty/Days: 30/30 at RETAIL | Claim pays at retail tier 3 |  |  |  | No Run | 1215036512
Product: SIMVASTATIN 10mg NDC: [PHONE] Qty/Days: 30/30 at RETAIL | Claim pays at retail tier 2 |  |  |  | No Run | 1215036512
Product: HUMALOG 100/ml NDC: [PHONE] Qty/Days: 60/60 at RETAIL | Claim pays at 2 x retail tier 3 |  |  |  | No Run | 1215036512
Product: HUMALOG 100/ml NDC: [PHONE] Qty/Days: 90/90 at RETAIL | Claim returns reject 7X=DAYS SUPPLY EXCEEDS PLAN LIMITATION -or- Claim pays at VBID mail tier 3 (Smart90) |  |  |  | No Run | 1215036512
Product: LIPITOR 10mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | Claim pays at mail tier 4 |  |  |  | No Run | 1558443911
Product: HUMALOG 100/ml NDC: [PHONE] Qty/Days: 90/90 at MAIL | Claim pays at VBID mail tier 3 |  |  |  | No Run | 1558443911
Product: SIMVASTATIN 10mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | Claim pays at VBID mail tier 2 |  |  |  | No Run | 1558443911
Product: FARXIGA 10mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | Claim pays at VBID mail tier 3 |  |  |  | No Run | 1558443911
Product: FARXIGA 5mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | Claim pays at VBID mail tier 3 |  |  |  | No Run | 1558443911
Product: XIGDUO XR 10-1000mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | Claim pays at VBID mail tier 3 |  |  |  | No Run | 1558443911
Product: XIGDUO XR 10mg-500mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | Claim pays at VBID mail tier 3 |  |  |  | No Run | 1558443911
Product: XIGDUO XR 2.5-1000mg NDC: [PHONE] Qty/Days: 60/90 at MAIL | Claim pays at VBID mail tier 3 |  |  |  | No Run | 1558443911
Product: XIGDUO XR 5mg-500mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | Claim pays at VBID mail tier 3 |  |  |  | No Run | 1558443911
Product: XIGDUO XR 5mg-1000mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | Claim pays at VBID mail tier 3 |  |  |  | No Run | 1558443911
Product: INVOKAMET 150-1000mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | After transition fill, claim returns reject MR=DRUG NOT ON FORMULARY. Created PA and claim pays at mail tier 4. |  |  |  | No Run | 1558443911
Product: INVOKAMET 150-500mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | After transition fill, claim returns reject MR=DRUG NOT ON FORMULARY. Created PA and claim pays at mail tier 4. |  |  |  | No Run | 1558443911
Product: INVOKAMET 50-1000mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | After transition fill, claim returns reject MR=DRUG NOT ON FORMULARY. Created PA and claim pays at mail tier 4. |  |  |  | No Run | 1558443911
Product: INVOKAMET 50mg-500mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | After transition fill, claim returns reject MR=DRUG NOT ON FORMULARY. Created PA and claim pays at mail tier 4. |  |  |  | No Run | 1558443911
Product: INVOKAMET XR 150-1000mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | After transition fill, claim returns reject MR=DRUG NOT ON FORMULARY. Created PA and claim pays at mail tier 4. |  |  |  | No Run | 1558443911
Product: INVOKAMET XR 150-500mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | After transition fill, claim returns reject MR=DRUG NOT ON FORMULARY. Created PA and claim pays at mail tier 4. |  |  |  | No Run | 1558443911
Product: INVOKAMET XR 50-1000mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | After transition fill, claim returns reject MR=DRUG NOT ON FORMULARY. Created PA and claim pays at mail tier 4. |  |  |  | No Run | 1558443911
Product: INVOKAMET XR 50mg-500mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | After transition fill, claim returns reject MR=DRUG NOT ON FORMULARY. Created PA and claim pays at mail tier 4. |  |  |  | No Run | 1558443911
Product: INVOKANA 100mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | After transition fill, claim returns reject MR=DRUG NOT ON FORMULARY. Created PA and claim pays at mail tier 4. |  |  |  | No Run | 1558443911
Product: INVOKANA 100mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | After transition fill, claim returns reject MR=DRUG NOT ON FORMULARY. Created PA and claim pays at mail tier 4. |  |  |  | No Run | 1558443911
Product: INVOKANA 300mg NDC: [PHONE]  Qty/Days: 90/90 at MAIL | After transition fill, claim returns reject MR=DRUG NOT ON FORMULARY. Created PA and claim pays at mail tier 4. |  |  |  | No Run | 1558443911
Product: INVOKANA  300mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | After transition fill, claim returns reject MR=DRUG NOT ON FORMULARY. Created PA and claim pays at mail tier 4. |  |  |  | No Run | 1558443911
5 tier specialty  / Excl Accredo = N
Test Case Name/Description | Expected Results | Actual Results/Comments | Tester | Test Date | Status | Test Pharmacy NPI | Test Member ID
Product: LIPITOR 10mg NDC: [PHONE] Qty/Days: 30/30 at RETAIL | Claim pays at retail tier 3 |  |  |  | No Run | 1215036512
Product: HUMALOG 100/ml NDC: [PHONE] Qty/Days: 30/30 at RETAIL | Claim pays at retail tier 2 |  |  |  | No Run | 1215036512
Product: SIMVASTATIN 10mg NDC: [PHONE] Qty/Days: 30/30 at RETAIL | Claim pays at retail tier 1 |  |  |  | No Run | 1215036512
Product: HUMALOG 100/ml NDC: [PHONE] Qty/Days: 60/60 at RETAIL | Claim pays at 2 x retail tier 2 |  |  |  | No Run | 1215036512
Product: HUMALOG 100/ml NDC: [PHONE] Qty/Days: 90/90 at RETAIL | Claim returns reject 7X=DAYS SUPPLY EXCEEDS PLAN LIMITATION -or- Claim pays at mail tier 2 (Smart90) |  |  |  | No Run | 1215036512
Product: LIPITOR 10mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | Claim pays at mail tier 3 |  |  |  | No Run | 1558443911
Product: HUMALOG 100/ml NDC: [PHONE] Qty/Days: 90/90 at MAIL | Claim pays at mail tier 2 |  |  |  | No Run | 1558443911
Product: SIMVASTATIN 10mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | Claim pays at mail tier 1 |  |  |  | No Run | 1558443911
Product: AUBAGIO 14mg NDC: [PHONE] Qty/Days: 30/30 at ACCREDO SPECIALTY | Claim pays at specialty tier 5 |  |  |  | No Run | 1851346522
Product: GRANIX 300mcg/ml NDC: [PHONE] Qty/Days: 1/30 at ACCREDO SPECIALTY | Claim pays at specialty tier 4 |  |  |  | No Run | 1851346522
Product: CALCIUM FOLINATE NDC: [PHONE] Qty/Days: 1/30 at CAREMARK SPECIALTY | Claim returns reject 70=PRODUCT/SERVICE NOT COVERED. After override, claim pays at specialty tier 3 |  |  |  | No Run | 1902887805
Product: VIGABATRIN 500mg NDC: [PHONE] Qty/Days: 30/30 at CAREMARK SPECIALTY | Claim pays at specialty tier 1 |  |  |  | No Run | 1902887805
5 tier specialty / Excl Accredo = N / VBID mail
Test Case Name/Description | Expected Results | Actual Results/Comments | Tester | Test Date | Status | Test Pharmacy NPI | Test Member ID
Product: LIPITOR 10mg NDC: [PHONE] Qty/Days: 30/30 at RETAIL | Claim pays at specialty retail tier 3 |  |  |  | No Run | 1215036512
Product: HUMALOG 100/ml NDC: [PHONE] Qty/Days: 30/30 at RETAIL | Claim pays at specialty retail tier 2 |  |  |  | No Run | 1215036512
Product: SIMVASTATIN 10mg NDC: [PHONE] Qty/Days: 30/30 at RETAIL | Claim pays at specialty retail tier 1 |  |  |  | No Run | 1215036512
Product: HUMALOG 100/ml NDC: [PHONE] Qty/Days: 60/60 at RETAIL | Claim pays at 2 x specialty retail tier 2 |  |  |  | No Run | 1215036512
Product: HUMALOG 100/ml NDC: [PHONE] Qty/Days: 90/90 at RETAIL | Claim returns reject 7X=DAYS SUPPLY EXCEEDS PLAN LIMITATION -or- Claim pays at VBID mail tier 2 (Smart90) |  |  |  | No Run | 1215036512
Product: LIPITOR 10mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | Claim pays at mail tier 3 |  |  |  | No Run | 1558443911
Product: HUMALOG 100/ml NDC: [PHONE] Qty/Days: 90/90 at MAIL | Claim pays at VBID mail tier 2 |  |  |  | No Run | 1558443911
Product: SIMVASTATIN 10mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | Claim pays at VBID mail tier 1 |  |  |  | No Run | 1558443911
Product: AUBAGIO 14mg NDC: [PHONE] Qty/Days: 30/30 at ACCREDO SPECIALTY | Claim pays at specialty tier 5 |  |  |  | No Run | 1851346522
Product: GRANIX 300mcg/ml NDC: [PHONE] Qty/Days: 1/30 at ACCREDO SPECIALTY | Claim pays at specialty tier 4 |  |  |  | No Run | 1851346522
Product: CALCIUM FOLINATE NDC: [PHONE] Qty/Days: 1/30 at CAREMARK SPECIALTY | Claim returns reject 70=PRODUCT/SERVICE NOT COVERED. After override, claim pays at specialty tier 3 |  |  |  | No Run | 1902887805
Product: VIGABATRIN 500mg NDC: [PHONE] Qty/Days: 30/30 at CAREMARK SPECIALTY | Claim pays at specialty tier 1 |  |  |  | No Run | 1902887805
Product: FARXIGA 10mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | Claim pays at VBID mail tier 2 |  |  |  | No Run | 1558443911
Product: FARXIGA 5mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | Claim pays at VBID mail tier 2 |  |  |  | No Run | 1558443911
Product: XIGDUO XR 10-1000mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | Claim pays at VBID mail tier 2 |  |  |  | No Run | 1558443911
Product: XIGDUO XR 10mg-500mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | Claim pays at VBID mail tier 2 |  |  |  | No Run | 1558443911
Product: XIGDUO XR 2.5-1000mg NDC: [PHONE] Qty/Days: 60/90 at MAIL | Claim pays at VBID mail tier 2 |  |  |  | No Run | 1558443911
Product: XIGDUO XR 5mg-500mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | Claim pays at VBID mail tier 2 |  |  |  | No Run | 1558443911
Product: XIGDUO XR 5mg-1000mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | Claim pays at VBID mail tier 2 |  |  |  | No Run | 1558443911
Product: INVOKAMET 150-1000mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | After transition fill, claim returns reject MR=DRUG NOT ON FORMULARY. Created PA and claim pays at mail tier 3. |  |  |  | No Run | 1558443911
Product: INVOKAMET 150-500mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | After transition fill, claim returns reject MR=DRUG NOT ON FORMULARY. Created PA and claim pays at mail tier 3. |  |  |  | No Run | 1558443911
Product: INVOKAMET 50-1000mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | After transition fill, claim returns reject MR=DRUG NOT ON FORMULARY. Created PA and claim pays at mail tier 3. |  |  |  | No Run | 1558443911
Product: INVOKAMET 50mg-500mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | After transition fill, claim returns reject MR=DRUG NOT ON FORMULARY. Created PA and claim pays at mail tier 3. |  |  |  | No Run | 1558443911
Product: INVOKAMET XR 150-1000mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | After transition fill, claim returns reject MR=DRUG NOT ON FORMULARY. Created PA and claim pays at mail tier 3. |  |  |  | No Run | 1558443911
Product: INVOKAMET XR 150-500mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | After transition fill, claim returns reject MR=DRUG NOT ON FORMULARY. Created PA and claim pays at mail tier 3. |  |  |  | No Run | 1558443911
Product: INVOKAMET XR 50-1000mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | After transition fill, claim returns reject MR=DRUG NOT ON FORMULARY. Created PA and claim pays at mail tier 3. |  |  |  | No Run | 1558443911
Product: INVOKAMET XR 50mg-500mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | After transition fill, claim returns reject MR=DRUG NOT ON FORMULARY. Created PA and claim pays at mail tier 3. |  |  |  | No Run | 1558443911
Product: INVOKANA 100mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | After transition fill, claim returns reject MR=DRUG NOT ON FORMULARY. Created PA and claim pays at mail tier 3. |  |  |  | No Run | 1558443911
Product: INVOKANA 100mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | After transition fill, claim returns reject MR=DRUG NOT ON FORMULARY. Created PA and claim pays at mail tier 3. |  |  |  | No Run | 1558443911
Product: INVOKANA 300mg NDC: [PHONE]  Qty/Days: 90/90 at MAIL | After transition fill, claim returns reject MR=DRUG NOT ON FORMULARY. Created PA and claim pays at mail tier 3. |  |  |  | No Run | 1558443911
Product: INVOKANA  300mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | After transition fill, claim returns reject MR=DRUG NOT ON FORMULARY. Created PA and claim pays at mail tier 3. |  |  |  | No Run | 1558443911
5 tier specialty  / Excl Accredo = Y
Test Case Name/Description | Expected Results | Actual Results/Comments | Tester | Test Date | Status | Test Pharmacy NPI | Test Member ID
Product: LIPITOR 10mg NDC: [PHONE] Qty/Days: 30/30 at RETAIL | Claim pays at specialty retail tier 3 |  |  |  | No Run | 1215036512
Product: HUMALOG 100/ml NDC: [PHONE] Qty/Days: 30/30 at RETAIL | Claim pays at specialty retail tier 2 |  |  |  | No Run | 1215036512
Product: SIMVASTATIN 10mg NDC: [PHONE] Qty/Days: 30/30 at RETAIL | Claim pays at specialty retail tier 1 |  |  |  | No Run | 1215036512
Product: HUMALOG 100/ml NDC: [PHONE] Qty/Days: 60/60 at RETAIL | Claim pays at 2 x specialty retail tier 2 |  |  |  | No Run | 1215036512
Product: HUMALOG 100/ml NDC: [PHONE] Qty/Days: 90/90 at RETAIL | Claim returns reject 7X=DAYS SUPPLY EXCEEDS PLAN LIMITATION -or- Claim pays at mail tier 2 (Smart90) |  |  |  | No Run | 1215036512
Product: LIPITOR 10mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | Claim pays at mail tier 3 |  |  |  | No Run | 1558443911
Product: HUMALOG 100/ml NDC: [PHONE] Qty/Days: 90/90 at MAIL | Claim pays at mail tier 2 |  |  |  | No Run | 1558443911
Product: SIMVASTATIN 10mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | Claim pays at mail tier 1 |  |  |  | No Run | 1558443911
Product: AUBAGIO 14mg NDC: [PHONE] Qty/Days: 30/30 at ACCREDO SPECIALTY | Claim pays at specialty tier 5 |  |  |  | No Run | 1851346522
Product: GRANIX 300mcg/ml NDC: [PHONE] Qty/Days: 1/30 at ACCREDO SPECIALTY | Claim pays at specialty tier 4 |  |  |  | No Run | 1851346522
Product: CALCIUM FOLINATE NDC: [PHONE] Qty/Days: 1/30 at CAREMARK SPECIALTY | Claim returns reject 70=PRODUCT/SERVICE NOT COVERED. After override, claim returns reject 4W = MUST DISPENSE THROUGH SPECIALTY PHARMACY |  |  |  | No Run | 1902887805
Product: VIGABATRIN 500mg NDC: [PHONE] Qty/Days: 30/30 at CAREMARK SPECIALTY | Claim returns reject 4W = MUST DISPENSE THROUGH SPECIALTY PHARMACY |  |  |  | No Run | 1902887805
5 tier specialty / Excl Accredo = Y / VBID mail
Test Case Name/Description | Expected Results | Actual Results/Comments | Tester | Test Date | Status | Test Pharmacy NPI | Test Member ID
Product: LIPITOR 10mg NDC: [PHONE] Qty/Days: 30/30 at RETAIL | Claim pays at specialty retail tier 3 |  |  |  | No Run | 1215036512
Product: HUMALOG 100/ml NDC: [PHONE] Qty/Days: 30/30 at RETAIL | Claim pays at specialty retail tier 2 |  |  |  | No Run | 1215036512
Product: SIMVASTATIN 10mg NDC: [PHONE] Qty/Days: 30/30 at RETAIL | Claim pays at specialty retail tier 1 |  |  |  | No Run | 1215036512
Product: HUMALOG 100/ml NDC: [PHONE] Qty/Days: 60/60 at RETAIL | Claim pays at 2 x specialty retail tier 2 |  |  |  | No Run | 1215036512
Product: HUMALOG 100/ml NDC: [PHONE] Qty/Days: 90/90 at RETAIL | Claim returns reject 7X=DAYS SUPPLY EXCEEDS PLAN LIMITATION -or- Claim pays at VBID mail tier 2 (Smart90) |  |  |  | No Run | 1215036512
Product: LIPITOR 10mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | Claim pays at mail tier 3 |  |  |  | No Run | 1558443911
Product: HUMALOG 100/ml NDC: [PHONE] Qty/Days: 90/90 at MAIL | Claim pays at VBID mail tier 2 |  |  |  | No Run | 1558443911
Product: SIMVASTATIN 10mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | Claim pays at VBID mail tier 1 |  |  |  | No Run | 1558443911
Product: AUBAGIO 14mg NDC: [PHONE] Qty/Days: 30/30 at ACCREDO SPECIALTY | Claim pays at specialty tier 5 |  |  |  | No Run | 1851346522
Product: GRANIX 300mcg/ml NDC: [PHONE] Qty/Days: 1/30 at ACCREDO SPECIALTY | Claim pays at specialty tier 4 |  |  |  | No Run | 1851346522
Product: CALCIUM FOLINATE NDC: [PHONE] Qty/Days: 1/30 at CAREMARK SPECIALTY | Claim returns reject 70=PRODUCT/SERVICE NOT COVERED. After override, claim returns reject 4W = MUST DISPENSE THROUGH SPECIALTY PHARMACY |  |  |  | No Run | 1902887805
Product: VIGABATRIN 500mg NDC: [PHONE] Qty/Days: 30/30 at CAREMARK SPECIALTY | Claim returns reject 4W = MUST DISPENSE THROUGH SPECIALTY PHARMACY |  |  |  | No Run | 1902887805
Product: FARXIGA 10mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | Claim pays at VBID mail tier 2 |  |  |  | No Run | 1558443911
Product: FARXIGA 5mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | Claim pays at VBID mail tier 2 |  |  |  | No Run | 1558443911
Product: XIGDUO XR 10-1000mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | Claim pays at VBID mail tier 2 |  |  |  | No Run | 1558443911
Product: XIGDUO XR 10mg-500mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | Claim pays at VBID mail tier 2 |  |  |  | No Run | 1558443911
Product: XIGDUO XR 2.5-1000mg NDC: [PHONE] Qty/Days: 60/90 at MAIL | Claim pays at VBID mail tier 2 |  |  |  | No Run | 1558443911
Product: XIGDUO XR 5mg-500mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | Claim pays at VBID mail tier 2 |  |  |  | No Run | 1558443911
Product: XIGDUO XR 5mg-1000mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | Claim pays at VBID mail tier 2 |  |  |  | No Run | 1558443911
Product: INVOKAMET 150-1000mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | After transition fill, claim returns reject MR=DRUG NOT ON FORMULARY. Created PA and claim pays at mail tier 3. |  |  |  | No Run | 1558443911
Product: INVOKAMET 150-500mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | After transition fill, claim returns reject MR=DRUG NOT ON FORMULARY. Created PA and claim pays at mail tier 3. |  |  |  | No Run | 1558443911
Product: INVOKAMET 50-1000mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | After transition fill, claim returns reject MR=DRUG NOT ON FORMULARY. Created PA and claim pays at mail tier 3. |  |  |  | No Run | 1558443911
Product: INVOKAMET 50mg-500mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | After transition fill, claim returns reject MR=DRUG NOT ON FORMULARY. Created PA and claim pays at mail tier 3. |  |  |  | No Run | 1558443911
Product: INVOKAMET XR 150-1000mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | After transition fill, claim returns reject MR=DRUG NOT ON FORMULARY. Created PA and claim pays at mail tier 3. |  |  |  | No Run | 1558443911
Product: INVOKAMET XR 150-500mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | After transition fill, claim returns reject MR=DRUG NOT ON FORMULARY. Created PA and claim pays at mail tier 3. |  |  |  | No Run | 1558443911
Product: INVOKAMET XR 50-1000mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | After transition fill, claim returns reject MR=DRUG NOT ON FORMULARY. Created PA and claim pays at mail tier 3. |  |  |  | No Run | 1558443911
Product: INVOKAMET XR 50mg-500mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | After transition fill, claim returns reject MR=DRUG NOT ON FORMULARY. Created PA and claim pays at mail tier 3. |  |  |  | No Run | 1558443911
Product: INVOKANA 100mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | After transition fill, claim returns reject MR=DRUG NOT ON FORMULARY. Created PA and claim pays at mail tier 3. |  |  |  | No Run | 1558443911
Product: INVOKANA 100mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | After transition fill, claim returns reject MR=DRUG NOT ON FORMULARY. Created PA and claim pays at mail tier 3. |  |  |  | No Run | 1558443911
Product: INVOKANA 300mg NDC: [PHONE]  Qty/Days: 90/90 at MAIL | After transition fill, claim returns reject MR=DRUG NOT ON FORMULARY. Created PA and claim pays at mail tier 3. |  |  |  | No Run | 1558443911
Product: INVOKANA  300mg NDC: [PHONE] Qty/Days: 90/90 at MAIL | After transition fill, claim returns reject MR=DRUG NOT ON FORMULARY. Created PA and claim pays at mail tier 3. |  |  |  | No Run | 1558443911
Alternate drugs to use if Lipitor, Humalog and Simvastatin take $0 copays for an account
Test Case Name/Description | Expected Results
PRODUCT: FLUORIDEX 1.1% paste NDC: [PHONE] Qty/Days: 1108/30 days at RETAIL (apply HD override) | Claim pays at retail tier 3
Product: ADAPALENE 0.3% Gel NDC: [PHONE] Qty/Days: 45/30 at RETAIL | Claim pays at retail tier 2
Product: ISOTRETINOIN 20mg capsules NDC: [PHONE] Qty/Days: 30/30 at RETAIL | Claim pays at retail tier 1
Product: ADAPALENE 0.3% Gel NDC: [PHONE] Qty/Days: 90/60 at RETAIL | Claim pays at 2 x retail tier 2
Product: ADAPALENE 0.3% Gel NDC: [PHONE] Qty/Days: 135/90 at RETAIL | Claim returns reject 7X=DAYS SUPPLY EXCEEDS PLAN LIMITATION
PRODUCT: FLUORIDEX 1.1% paste NDC: [PHONE] Qty/Days: 3324/90 days at MAIL (apply HD override) | Claim pays at mail tier 3
Product: ADAPALENE 0.3% Gel NDC: [PHONE] Qty/Days: 135/90 at MAIL | Claim pays at mail tier 2
Product: ISOTRETINOIN 20mg capsules NDC: [PHONE] Qty/Days: 90/90 at MAIL (PA on file) | Claim pays at mail tier 1