"Default" PA Default
Field that defines the type of default table that will be loaded by the system for a new criteria.
Override Type
GCN
Eleven-digit long value that is formally called "National Drug Code"
NDC
Mainframe field used to approve medications at specific tier.
Price Point
Field used for Medicare B vs D criteria.
Med D Override
Number of fields that are automatically filled by the system when a "default" PA Default is created.
Process of adding GCN values to the PA Default mainframe table to approve formulations in addition to the requested medication.
Hardcoding
Drug Marker Type value that overrides rejection without entering a PA.
Global
Other name for applying a single-source brand (SSB) copay override to multi-source-brand (MSB) drugs.
MAC penalty override
Restricts PA to generics only. (Field and Value)
Brand/Generic = Generic
Defines the type(s) of claim submission(s) that should be approvable with the PA.
Claim Submission Type
Line of business that automatically expands PAs across strengths and dosage forms overnight
Medicare
Drug Marker Type value that should be used for Retail Refill Allowance admin criteria.
GRRA
Three fields that should be used to pay medications at a specific copay percentage.
Copay Override Type, Copay Units, Copay Value MSR
Overrides the Annual Benefit cap. (Field and Value)
Cap Override = Annual Benefit
Drug Marker Type value that enters PA for the requested medication based on the medication's STC, HICL, STR, Dose, and RT.
GCN
Three fields required to enter GCN-expanded PAs for different medications in a commercial criteria.
Drug Marker Type, Drug Marker Value, Expanded GCN Code
Value of the Drug Marker Type that enters PA for all medications in a specific DCRS drug list.
Drug-List
Type of criteria that normally issues zero-dollar copy overrides to all members.
Health Care Reform (HCR)
Forces medication to pay under Medicare Part D for when not normally payable under Parts B or D but will be used for indication covered under Part D. (Field and Value)
Med D Override = Super Override
Field that determines if the PAs will be entered automatically by the system or manually by a representative or pharmacist.
Auto Update Indicator
Name of the medication that is excluded from GCN expansion.
Cialis
Number of rows needed in the PA default to ONLY approve Dexcom products.
23
A criteria that targets SSB, MSB, and generic drugs needs to pay SSB at SSB copay, MSB at SSB copay, and generics at generic copay. What will be the values of the Drug Marker Type, Brand Copay Override, and Brand/Generic fields in the mainframe?
There will be two rows:
Row 1 to approve brand drugs with Drug Marker Type = GCN, Brand Copay Override = SSB, and Brand/Generic = Brand (SSN + MSB).
Row 2 to approve generic drugs with Drug Marker Type = NDC, Brand Copay Override = blank, and Brand/Generic = Generic;
Overrides QLS or QLD rules for non-Cigna commercial criteria. [Field(s) and Value]
PA Override = MQ – MME Quantity Required with MME Quantity box filled.