Bruce Wilkinson. Formulary & Benefit (F&B) Copay Summary Recommendation

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1 Bruce Wilkinson Formulary & Benefit (F&B) Copay Summary Recommendation

2 F&B Summary Copay Usage Goal: Use the Summary Copay files in a consistent manner with other F&B file types, specifically formulary status Options: 1. Use As-Is (but explain how it should be used) 2. Reuse the Formulary Status Design for nonlisted drugs to represent various copays 3. Modify current design to improve usability.

3 Formulary Status Header

4 Current Copay Summary Design

5 Non-Listed Drug Categories Formulary Header Copay Summary* Prescription Brand (Single Source) Prescription Generic Authorized Generic (aka Branded Generic ) Compound Drug Brand Over the Counter x (only as OTC) Generic Over the Counter x (only as OTC) (Medical) Supply Not specified Any Others??? * Product Type

6 Working Example Formulary Header (default norm for this group/plan ) Copay Summary* (default norm for this group/plan ) Example medication Prescription Brand e.g. Non-formulary $50 Celebrex/Humira/etc Prescription Generic e.g. Preferred $5 Lisinopril/etc Authorized Generic (aka Branded Generic ) Sunset Compound Drug Sunset Brand Over the Counter x (only as OTC) Generic Over the Counter x (only as OTC) (Medical) Supply Need an OTC indicator for the Formulary Header. Copay Summary already supports OTC Need an OTC indicator, but do we need brand v generic? Any Others? * Product Type

7 ECL Product Type (964-JA) Working Values CODE DESCRIPTION Value Limitation (red is new change) Ø Not Specified Not allowed to be used 1 Single source a clinical formulation that is only available from a single distributor. 2 Authorized Generic (aka Branded Generic ) the originating company is authorizing the manufacturer of the drug using their New Drug Application (NDA). Often introduced as patent protection for the original branded formulation when nearing expiration. E.g. Pfizer and its subsidiary Greenstone. Sunset this value 3 Generic the pharmaceutically equivalent product of a branded product introduced by additional distributors after patient protection has expired on the brand product. Manufactured under an Abbreviated New Drug Application (ANDA). 4 O.T.C. (over the counter) drugs and other pharmaceuticals that may be purchased without a prescription. These products do not carry the legend: Caution: Federal Law Prohibits Dispensing Without a Prescription. 5 Compound a combination of pharmaceutical ingredients that is created extemporaneously; i.e. the combination is not available pre-packaged from a manufacturer. 6 Supply consumable health care items, such as pledgets, syringes, test strips. Distinct from Durable Medical Equipment (DME) which is generally not consumed by its use. 7 Branded O.T.C. (over the counter) branded drugs and other pharmaceuticals that may be purchased without a prescription. These products do not carry the legend: Caution: Federal Law Prohibits Dispensing Without a Prescription. 8 Generic O.T.C. (over the counter) generic drugs and other pharmaceuticals that may be purchased without a prescription. These products do not carry the legend: Caution: Federal Law Prohibits Dispensing Without a Prescription. Sunset Replaced by Values 7 and 8 reinstate this value Sunset this value Sunset this value and open up value 4 as a single OTC code Sunset this value and open up value 4 as a single OTC code A Any Copay is consistent across all product types within a specific formulary status.

8 ECL Product Type (964-JA) Final Determination Values CODE DESCRIPTION Value Limitation Ø Not Specified Not allowed to be used 1 Single source a clinical formulation that is only available from a single distributor. 3 Generic the pharmaceutically equivalent product of a branded product introduced by additional distributors after patient protection has expired on the brand product. Manufactured under an Abbreviated New Drug Application (ANDA). 6 Supply consumable health care items, such as pledgets, syringes, test strips. Distinct from Durable Medical Equipment (DME) which is generally not consumed by its use. 7 Branded O.T.C. (over the counter) branded drugs and other pharmaceuticals that may be purchased without a prescription. These products do not carry the legend: Caution: Federal Law Prohibits Dispensing Without a Prescription. 8 Generic O.T.C. (over the counter) generic drugs and other pharmaceuticals that may be purchased without a prescription. These products do not carry the legend: Caution: Federal Law Prohibits Dispensing Without a Prescription. A Any Copay is consistent across all product types within a specific formulary status.

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