Stream: Da Vinci PDex Drug Formulary
Topic: Drug Tier Extension Interpretation
Courtney Bland (May 17 2021 at 20:18):
Good day all,
We have a difference of opinion on how we should appropriately use the drug tier extension on the Coverage Plan profile. To illustrate the confusion, I am going to make up an example. Let’s say we have plan A. Plan A has 5 drug tiers with one of the drug tiers being “preferred-generic”. “Preferred-generic” has 6 pharmacy types associated to it. Each of those pharmacy types have copay and/or coinsurance values associated to them.
1 month standard retail,
2 month standard retail,
3 month standard network retail,
1 month standard mail order,
2 month standard mail order and
3 month standard mail order
OPTION 1: costSharing extension is dependent upon the drug tier and mail order value.
With option 1, the drugTier extension will repeat twice for “preferred-generic”. One “preferred-generic” drugTier extension has a mail order set to true and the costSharing extension repeats three times with the following pharmacyType values:
1 month standard mail order,
2 month standard mail order and
3 month standard mail order
The second “preferred-generic” drugTier extension has a mail order value of false and the costSharing extension repeats three times with the following pharmacyType values:
1 month standard retail,
2 month standard retail,
3 month standard network retail
This option is based on the idea that the drug tier and mail order values, in combination, drive the pharmacy type for a given drug tier extension.
OPTION 2: costSharing extension is dependent upon the drug tier, but not the mail order value.
With option 2, the drugTier extension will not repeat for “preferred-generic”. It will appear only once. The mail order is set to true and the costSharing extension repeats six times. It has both mail order and retail pharmacy types.
1 month standard retail,
2 month standard retail,
3 month standard network retail,
1 month standard mail order,
2 month standard mail order and
3 month standard mail order
This option is based on the idea that the drug tier alone drives the pharmacy type and the mail order value doesn’t limit the pharmacy types that can appear for a given drug tier extension.
@Mark Neumuth
Last updated: Apr 12 2022 at 19:14 UTC
