Pricing
NDC/GPI
Accumulators
Plan option/Plan detailed page
Miscellaneous
100
In which options Ancillary charges will be coded or considered
Option 10/11/28 and 29
100
Processing qualifier is turned of for which sequences in plan option 10 NDC list?
seq- 6, 8, 9, 30, 310, 950
100
Deductible: Yes... Combined Medical and Pharmacy: Yes... Deductible: Non-Embedded... In Network Individual $: 1500.00 Family $: what is the basis code for the above scenario?
1
100
Funding Arrangement: ASO... Rider code: ASO... state Situs: NJ... tier type: drug type generic/brand... what is the plan qualifier foe above scenario?
U1-ASO*NJ
100
what action is required when Out-Of-Network Pharmacy is Not covered?
Plan option 3.3. 98 qualifier- N and remove price
200
what are the calculation codes that we use in compound table?
C,C
200
as per PhBIT diabetic supplies- covered - no Insulin Pump Supplies which NDC/GPI list do use in mail plan?
UGDB9
200
what should be the patient pay flags for deductible schedule when PhBIT is showing? Deductible-Yes Out Of Pocket Maximum- No Lifetime Maximum- Yes
N, Y
200
if the preferred product list is existing with qualifier "D" and year 2009... what is the action required?
Edit list- remove the qualifier and change the year to 2007
200
After creating the plan code, where do you attach your plan code and what is the path?
RxCLAIM™ Book 2  8 (Profile)  5 (Benefit – Plan Translation)  Pick up Carrier with 7(Table)- add BPL, Plan code
300
Which calculation code do we code in patient pay T4 group directing?
"D"
300
Erectile and Sexual Dysfunction: Covered - Standard... E.S.D. Notification Applies: Yes.... which NDC/GPI lists do we implement in retail plan and at what sequence?
UGED2 (Seq 375) UGES01(Seq 380)
300
What is the response accumulation code when PhBIT shows Deductible: Yes... Out of Pocket Maximum: Yes... Annual Max: N/A... Combined Medical and Pharmacy: Yes, Out Of Pocket only...
2
300
At which plan options and sequences do we code ECOB overrides?
Plan option-2. 200, 230, 240, 250, 400, 420, 430, 440 Plan option-3. 92
300
AS400 Path to attach your plan code while testing?
1. Eligibility/Claim Transaction- 1. Carrier/Account/Group-3. Group/Member-F7 eligibility- 2 edit- plan code and copays
400
In PhBIT showing Pre-packed medications covered- Covered - 3 copays for 90 days, which copay schedule do we use for the default lists?
Step3
400
Pharmacy Benefit Type: Large Group - ACA PPD... Business Segment: Small Group... Group State Situs: NY... Rider code :2017... PDL Exclusion Program: Customize... which NDC/GPI list do we use and the sequence?
sequence: 20 GPI- UPXX000251 NDC-UPXXL3
400
Deductible: Yes, Out of Pocket Maximum: Yes... Combined Medical and Pharmacy: Yes... Deductible and Out Of Pocket... Is the Out Of Pocket: Non-Embedded... Out Of Pocket Applies to: Deductible and Copays... In Network Individual $ 3000.00 Family $ 6000.00 Ancillary Charges Accumulate to Out-of-Pocket Max: No.. what is the Basis code, Accumulation code, OOP Sch Integrated Pharmacy & Medical for OOP schedule?
Basis code- 4 Accumulation code-6 OOP Sch Integrated Pharmacy & Medical-2
400
Fully insured plan does not have mail order.... what is the required action and at what option?
Remove C-MO6 and change the NDC/GPI list qualifier to "B" for BRIOVA and RXSMS
400
Effective date:07/20/2017... Mail Service Member Select... Drug List: New Standard Maintenance Drug List... Number Of Retail Fills: Initial Fill and One Refill Allowed... Benefit: Reject... Mail Serv Prod Benefit Textbox/A... Web Portal Opt-Out: No... What is effective date that we use in plan option 18, message code and GPI/NDC list.
08/01/17, MSMS2FILL and UXMSMS1
500
Please find the Patient pay schedule for Retail Days Supply: 31 with Patient Pay Comparison Code 'L' Mandatory: Apply Tier 1 copay + Ancillary Charges..
"X3TP444G3O"
500
Standard Clinical Program - Prior Authorization- covered... which NDC/GPI list do we use in traditional mail River vally plan?
UG1PB2 NDC/GPI
500
Deductible: Yes, Out of Pocket Maximum: Yes... Out Of Pocket Applies to: Copays only... The Out Of Pocket: Non-Embedded... Combined Medical and Pharmacy: Yes Deductible and Out Of Pocket... In Network Individual $ Family $ 8000.00... Out Of Pocket Applies to: Copays only.... Ancillary Charges Accumulate to Out-of-Pocket Maximum: Yes.... Basis code, Accumulation code, OOP Sch Integrated Pharmacy & Medical?
Basis code-2 Accumulation code- B Integrated Pharmacy & Medical-B
500
As per PhBIT Self-Administered Injectable = NOT COVERED... Non-Self-Administered Injectable = NOT COVERED... what is the action required in plan option 18 for ROA ID IR and SC?
IR- Term SC- Active
500
BPL ID: 332A2S Copied BPL ID: 39B99 Pharmacy Benefit Type:Small Group-EHB... Business Segment: Small Group... Funding Arrangement: Fully Insured... Prescription Drug List: Advantage (Standard)... Rider Code: 2017... ORx Carrier Id: UHCPRIM01... For above scenario where do copy your retail plan code and what is the plan description?
*FSPRM11A and UXEHB "Y" RTL
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