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Data Elements Related to Formulary & Benefit Standard

Name: Formulary & Benefit Standard
Definition: Provides a standard means for pharmacy benefit payers (including health plans and Pharmacy Benefit Managers) to communicate formulary and benefit information to prescribers via technology vendor systems.
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Absolute Row NumberThe absolute row or line number in the file that contains the error.
Additional Message InformationFree text message.
Alternatives IDID for the alternative list
Change IdentifierIdentifies type of change being made.
Copay IDThe membership population to which the copay rule applies.
Copay List IDID for the benefit copay list
Copay List TypeCode identifying the type of copay being conveyed
Copay TierThis medication's Tier; an indication of the cost to the patient. Lower values represent lower cost to the patient (e.g., Tier 1 is less costly to the patient than Tier 2)
Coverage IDThe membership population to which the coverage rule applies.
Coverage List IDID for the coverage rule
Coverage List TypeCode identifying the type of coverage rule being conveyed
Data In ErrorCopy of the bad data
Days Supply Per CopayThe days' supply associated with the stated copay terms
Diagnosis CodeCode identifying the diagnosis of the patient.
Diagnosis Code QualifierCode qualifying the 'Diagnosis Code' (424-DO).
Drug Qualifier-Step DrugIndicates whether the Product/Service ID represents a specific medication versus a pharmacological class
Drug Reference NumberIdentifier for the drug from proprietary drug sources
Drug Reference Number -AlternativeIdentifier for the alternative drug from proprietary drug sources
Drug Reference Number-SourceIdentifier for the drug from proprietary drug sources
Drug Reference Number-Step DrugIdentifier for the drug from proprietary drug sources that is recommended to be tried first
Drug Reference QualifierCode value that identifies the source and type for the Drug Reference Number.
Drug Reference Qualifier-AlternativeCode value that identifies the source and type for the Drug Reference Number-Alternative.
Drug Reference Qualifier-SourceCode value that identifies the source and type for the Drug Reference Number-Source.
Drug Reference Qualifier-Step DrugCode value that identifies the source and type for the Drug Reference Number -Step Drug.
Extract DateDate the file was extracted from the internal source system
File TypeCode identifying whether the file contained is test or production data.
First Copay TermFirst Copay term (flat copay amount or percent copay) to be considered
Flat Copay AmountFixed copay amount
Formulary IDID for the formulary list
Formulary NameName for the formulary list
Formulary StatusStatus of the drug within the formulary.
Gender CodeCode identifying the gender of the individual.
List ActionIndicates whether this is a replacement list, list updates or a list delete
List Effective DateDate the list goes into effect
Load StatusCode explaining the status of the load
Maximum AgeMaximum age at which the drug is covered (inclusive).
Maximum Age QualifierCode qualifying the maximum age.
Maximum AmountMaximum amount for a quantity limit.
Maximum Amount QualifierThis field qualifies the amount in the Maximum Amount (933-GB).
Maximum Amount Time PeriodType of time period associated with the overall Maximum Amount Qualifier (934-GC).
Maximum Amount Time Period End DateEnding date of Specific Date Range
Maximum Amount Time Period Start DateStarting date of Specific Date Range
Maximum Amount Time Period UnitsNumber of units associated with the overall Maximum Amount Time Period (935-GF)
Maximum CopayMaximum total copay to be paid by the patient
Maximum Copay TierProvides the range within which the Copay Tier is stated. The highest Copay Tier within that range
Message-LongText message.
Message-ShortText message.
Minimum AgeMinimum age at which the drug is covered (inclusive).
Minimum Age QualifierCode qualifying the Minimum Age (944-GR).
Minimum CopayMinimum total copay to be paid by the patient
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