Formulary Roll-Up Supplement 2014-01-14

FORMULARY ROLL-UP SUPPLEMENT
Based on NCPDP Formulary And Benefit Standard Implementation Guide

Version 3 Release 0
Date: January 14, 2014
FORMULARY ROLL-UP SUPPLEMENT

PUBLISHED BY
SURESCRIPTS, L.L.C.
920 2ND AVENUE S.
MINNEAPOLIS, MN 55402
PHONE: 866-267-9482
FAX: 651-855-3001
2800 CRYSTAL DRIVE
ARLINGTON, VA 22202
PHONE: 866-797-3239
FAX: 703-921-2191
WWW.SURESCRIPTS.COM
Copyright 2014 by Surescripts, LLC.

All rights reserved. Proprietary and Confidential.
This document and all other documents, materials, and information, transmitted or orally communicated
by Surescripts in the course of the parties dealings constitute and are hereby designated as
proprietary and confidential information of Surescripts, and may not be reproduced or distributed (in
whole or in part) without the express written consent of Surescripts.
FOR SECTIONS OF THIS PARTICIPANT IMPLEMENTATION GUIDE

PERTAINING TO NCPDP STANDARDS:
Materials Reproduced With the Consent of
National Council for Prescription Drug Programs, Inc.
NCPDP
NCPDP is a registered trademark of the National Council for Prescription Drug Programs, Inc.
Membership of NCPDP acknowledges your support and commitment to implement these standards as
specified in the standards documentation. You further acknowledge that the Councils standards
documents and their predecessors include proprietary material protected under the U.S. Copyright Law
and that all rights remain with NCPDP.
Document Change Log

The table below tracks significant changes to the document made in the last few months.
Section
Section Title
Change Description
N/A First Publication
LAST PUBLISHED 1/14/14
COPYRIGHT 2014 BY SURESCRIPTS, LLC.

ALL RIGHTS RESERVED. PROPRIETARY AND CONFIDENTIAL
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Surescripts Formulary Roll-up Supplement
Table of Contents
TABLE OF CONTENTS
SECTION 1
1.1
1.2
Overview ...................................................................................................... 7
About this Guide .......................................................................................................... 7
Document References ................................................................................................. 7
SECTION 2
Transaction Overview................................................................................... 9
2.1
2.2
2.3
2.3.1
2.3.2
Formulary Roll-up Transaction flow ............................................................................. 9

Roll-up Process Diagram ........................................................................................... 10
Formulary Roll-up Exception reports ......................................................................... 11
Missing or Obsolete NDCs ........................................................................................ 11
Conflicting Data ......................................................................................................... 11

PAGE 5
Table of Contents

PAGE 6
OVERVIEW
SECTION 1
1.1
Overview
ABOUT THIS GUIDE

Formulary Roll-up Supplement Guide
This Formulary Roll-up Supplement Guide was created to inform Pharmacy
Benefit Managers (PBMs) about the process Surescripts performs for roll-up of
formulary information. This is a supplement to the Surescripts Prescription Benefit
Implementation Guide. Formulary information is provided to Surescripts by all
participant PBMs.
This data identifies formulary status, coverage, and copay data for the payers'
active members. Today, most PBMs are providing formulary files at the NDC-11
packaged drug level. All prescriber vendors prescribe at a dispensable drug level
(drug name, strength, and form). In order to display formulary correctly, the data
must be rolled up to a dispensable drug level. This process involves Surescripts
performing this roll-up feature before the data is supplied to the prescriber vendor.
Surescripts determines a representative NDC and rolls all formulary information to
this level.
During the roll-up process, Surescripts identifies discrepancies in the files
provided. Surescripts generates reports that indicate conflicts in formulary status,
coverage factors, and copay details. The reports will be made available to the
PBM for periodic download and review.
1.2
DOCUMENT REFERENCES
The following documents were referenced in creating this Implementation Guide:
Document Title
NCPDPs Formulary And Benefit Standard Implementation Guide (Version 3, Release 0)
Surescripts Prescription Benefit Implementation Guide

PAGE 7
Overview

PAGE 8
SECTION 2
2.1
Transaction Overview
TRANSACTION OVERVIEW
FORMULARY ROLL-UP TRANSACTION FLOW

The Surescripts Prescription Benefit & Medication History service provides
physicians with the electronic delivery of PBM member data in an ambulatory
setting. Through the prescriber vendor interface, the physician can request patient
information such as eligibility and pharmacy benefit coverage, formulary, and
medication history. The graphic below depicts the transaction flow between
participants in this process.
The PBM sends in Formulary and Benefits files. There is no change to the format or
process.
1. Surescripts processes the incoming files.
2. Surescripts determines which Drug Databases are available for roll-up.
3. Surescripts determines the representative NDC using the Drug Database.
4. Surescripts rolls-up all data in the files utilizing this Drug Reference NDC to
Representative NDC file. A separate roll-up is performed for each drug
database
5. Surescripts creates exception reports that show data that needs to be
reviewed.
6. Surescripts makes the rolled up data available to the prescriber vendors.
7. Prescriber vendors download the rolled up version of the data that was rolled
up using prescriber vendors' contracted database.
8. Surescripts makes the exception reports available to the PBMs. The reports will
be in the same location where the formulary response file is located.

PAGE 9
2.2
ROLL-UP PROCESS DIAGRAM

PAGE 10
2.3
FORMULARY ROLL-UP EXCEPTION REPORTS

Exception reports will show the PBM data that needs to be reviewed due to
inconsistencies, obsolete or questionable data. An initial set of reports will be
automatically created upon the initial load, and then available upon request. These
reports will be available in the same location as the formulary response file. See
Surescripts Prescription Benefit Implementation Guide for more information on
response files. Two sets of reports will always be available (current and the most
recent prior to the current). The exception reports available are described below.
2.3.1
MISSING OR OBSOLETE NDCS

Surescripts will provide PBMs with a report that shows how many NDCs within the
formulary files do not match or match to obsolete NDCs in the major drug
databases. Those NDCs that cannot be found will not be included in the roll-up
process since they cannot be identified. The NDCs that map to obsolete NDCs will
be used for the roll-up, but will not be candidates for the representative NDC being
provided to the prescriber vendors. These NDCs should be investigated by the
PBMs to verify their validity.
Example:
This report indicates the NDC in question (either missing or obsolete) and how many
times it occurs across all the formulary, coverage, and copay files.
2.3.2
NDC
Usage
Count
[00006383334]
63
[49884077486]
62
[49884077586]
62
[49884077686]
62
[00149075215]
62
[00023921805]
61
[00406142301]
61
[63481052270]
61
CONFLICTING DATA
Surescripts will provide PBMs with reports of conflicting or questionable data for
formulary files and coverage files. The reports include:
2.3.2.1 FORMULARY STATUS

These reports show differing formulary status within a prescribeable drug
grouping.

PAGE 11
Example: Conflicting Status

This report shows conflicting Formulary Status for the same Representative NDC:
Participant ID:P00000000000001
Source Name:PBMA (PBM name)
Extract Date:20120502 (Date PBM created the file)
Formulary Name: ABC
Formulary ID:1223
List Effective Date:5/2/2012 (Date this formulary takes effect)
List Action: F (Describes type of list: "F"=Full, "D"=Delete)
NDC (Source NDC)
Formulary Status
(Original Formulary
Status)
Representative NDC
Rolled up Formulary
Status
00143318801
00054252625
00904620560
00054252625
31722054401
00054252625
00054252625
00054252625
00054852625
00054252625
68462022001
00054252625
00143319001
00054253125
31722054601
00054253125
000542531252
00054253125
000548531252
00054253125
684620222014
00054253125
2.3.2.2 COVERAGE FILE DISCREPANCIES

These reports show differing formulary status within a dispensable drug name,
strength, form and grouping.
Example Age Limits
This report shows conflicting age limits for the same NDCs.
Source Name:PBMB (PBM Name)
Coverage List ID:12234
List Type:AL (Indicates this is age limit report)
List Action:F (Describes type of list: "F"=Full, "D"=Delete)
Coverage ID
NDC (Source NDC)
Representative NDC
Coverage List Value
COV123
00062016502
00062016501
Min Age:0 Y
Max Age:29 Y
COV123
00062016502
00062016501
Min Age:0 Y
Max Age:30 Y

PAGE 12
Coverage ID
NDC (Source NDC)
Representative NDC
Coverage List Value
COV123
00062017513
00062017512
Min Age:0 Y
Max Age:30 Y
COV123
00062017513
00062017512
Min Age:0 Y
Max Age:29 Y
COV123
00062019003
00062019002
Min Age:0 Y
Max Age:30 Y
COV123
00062019003
00062019002
Min Age:0 Y
Max Age:29 Y
COV123
00062019011
00062019011
Min Age:0 Y
Max Age:29 Y
COV123
00062019011
00062019011
Min Age:0 Y
Max Age:30 Y
COV123
00062020403
00062020402
Min Age:0 Y
Max Age:30 Y
COV123
00062020403
00062020402
Min Age:0 Y
Max Age:29 Y
COV123
00062020411
00062020411
Min Age:0 Y
Max Age:29 Y
COV123
00062020411
00062020411
Min Age:0 Y
Max Age:30 Y
COV123
00062027501
00062027501
Min Age:0 Y
Max Age:30 Y
COV123
00062027501
00062027501
Min Age:0 Y
Max Age:29 Y
COV123
00062047545
00062047542
Min Age:0 Y
Max Age:29 Y
COV123
00062047545
00062047542
Min Age:0 Y
Max Age:30 Y
Example Gender Limits

This report shows conflicting Gender Limits for the same NDCs:
Source Name:PBMB (PBM Name)
Coverage List ID:12234
List Type:GL (Indicates gender limits)
List Action:F (Describes type of list: "F"=Full, "D"=Delete
Coverage ID
NDC (Source NDC)
Representative NDC
Coverage List Value

PAGE 13
COV123
00062016502
00062016501
COV123
00062016502
00062016501
COV123
00062017513
00062017512
COV123
00062017513
00062017512
Example Quantity Limits

This report shows conflicting Quantity Limits for the same Representative NDCs:
Source Name:PBMD (PBM Name)
Coverage List ID:COVABC
List Type:QL (Indicates quantity limits)
Coverage ID
NDC (Source NDC)
Representative NDC
Coverage List Value
COVABC
00169406012
00169406012
Max Amount:6 QY DY
30
COVABC
00169406013
00169406012
Max Amount:9 QY DY
30
COVABC
00173068220
00173068220
Max Amount:36 QY DY
30
COVABC
00173068221
00173068220
Max Amount:16 QY DY
30
Example Step Medication

This report shows conflicting Step Medications for the same Representative NDCs:
Coverage List ID:COVABC
List Type's (Indicates step medication)
List Effective Date:5/2/2012 (date this formulary takes effect)
Coverage ID
NDC (Source NDC)
Representative NDC
Coverage List Value
COV900
00054327099
00054327099
Step Rep NDC:00186107008

Step ProductId:00186107008
Step Order:1
Step Drug Qualifier:SM
COV900
00054327099
00054327099

Step Order:2 Step Drug
Qualifier:SM
COV900
00054327099
00054327099


PAGE 14
Qualifier:SM
COV900
00054327099
00054327099

Qualifier:SM
Example Text Messages

The following report shows potentially conflicting text messages for the same NDC11 and
Representative NDC. The PBM will determine if a change needs to be made or if the
messages are intentional:
Source Name:PBMC (PBM Name)
Coverage List ID:COVBNN
List Type:TM (Indicates Text Messages)
Coverage ID
NDC (Source NDC)
Representative NDC
Coverage List Value
32550378
00004008694
00004008694
Short Message: Patient may

be responsible for copay
plus the cost difference
between brand and generic
Long Message: If a brand
product is dispensed when a
generic is available, patient
may be responsible for
copay plus the cost
difference between brand
and generic.
32550378
00004008694
00004008694
Short Message: Designated

Specialty Pharmacy
Program, Call PBM at 1800-237-2767
Long Message: Designated
Specialty Pharmacy
Program, Call PBM at 1800-237-2767

PAGE 15
2.3.2.3 COPAY FILE DISCREPANCIES

These reports show conflicting copays for percent copay, flat copay, or both for the
same Representative NDC:
Coverage List ID:COVDEF
List Type: DS (Indicates drug specific copay)
List Effective Date: 5/2/2012 (Date this formulary takes effect)
Copay ID
NDC (Source
NDC)
Representative
NDC
Pharmacy Type
Coverage List Value
56132212
00264315311
00264315311
Copay Tier: 2
Max Copay Tier: 3
56132212
00338500241
00264315311
Copay Tier: 1
Max Copay Tier: 3
56132212
00338500341
00264315511
Copay Tier:1
Max Copay Tier: 3
56132212
00264315511
00264315511
Copay Tier: 1
Max Copay Tier: 3

PAGE 16

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FORMULARY ROLL-UP SUPPLEMENT

Based on NCPDP Formulary And Benefit Standard Implementation Guide

Date: January 14, 2014

FORMULARY ROLL-UP SUPPLEMENT

Copyright 2014 by Surescripts, LLC.

FOR SECTIONS OF THIS PARTICIPANT IMPLEMENTATION GUIDE

Document Change Log

N/A First Publication

LAST PUBLISHED 1/14/14

COPYRIGHT 2014 BY SURESCRIPTS, LLC.

This page intentionally left blank.

LAST PUBLISHED 1/14/14

COPYRIGHT 2014 BY SURESCRIPTS, LLC.

Surescripts Formulary Roll-up Supplement

Formulary Roll-up Transaction flow ............................................................................. 9

LAST PUBLISHED 1/14/14

COPYRIGHT 2014 BY SURESCRIPTS, LLC.

Surescripts Formulary Roll-up Supplement

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LAST PUBLISHED 1/14/14

COPYRIGHT 2014 BY SURESCRIPTS, LLC.

Surescripts Formulary Roll-up Supplement

ABOUT THIS GUIDE

LAST PUBLISHED 1/14/14

COPYRIGHT 2014 BY SURESCRIPTS, LLC.

Surescripts Formulary Roll-up Supplement

This page intentionally left blank.

LAST PUBLISHED 1/14/14

COPYRIGHT 2014 BY SURESCRIPTS, LLC.

Surescripts Formulary Roll-up Supplement

FORMULARY ROLL-UP TRANSACTION FLOW

LAST PUBLISHED 1/14/14

COPYRIGHT 2014 BY SURESCRIPTS, LLC.

Surescripts Formulary Roll-up Supplement

ROLL-UP PROCESS DIAGRAM

LAST PUBLISHED 1/14/14

COPYRIGHT 2014 BY SURESCRIPTS, LLC.

Surescripts Formulary Roll-up Supplement

FORMULARY ROLL-UP EXCEPTION REPORTS

MISSING OR OBSOLETE NDCS

2.3.2.1 FORMULARY STATUS

LAST PUBLISHED 1/14/14

COPYRIGHT 2014 BY SURESCRIPTS, LLC.

Surescripts Formulary Roll-up Supplement

Example: Conflicting Status

NDC (Source NDC)

2.3.2.2 COVERAGE FILE DISCREPANCIES

NDC (Source NDC)

Coverage List Value

LAST PUBLISHED 1/14/14

COPYRIGHT 2014 BY SURESCRIPTS, LLC.

Surescripts Formulary Roll-up Supplement

NDC (Source NDC)

Coverage List Value

Example Gender Limits

LAST PUBLISHED 1/14/14

NDC (Source NDC)

Coverage List Value

COPYRIGHT 2014 BY SURESCRIPTS, LLC.

Surescripts Formulary Roll-up Supplement

Example Quantity Limits

NDC (Source NDC)

Coverage List Value