Formulary IDs and Eligibility Fields Overview

🟪 audience pbms/payers + provider/ehr vendors this content applies to both trading partner types and includes requirements or workflows shared across both sides of the transaction as part of the upgrade to formulary v60, new formulary ids must be communicated by pbm/payer partners to support the newly added list types these ids will be communicated by the pbm/payers in the existing 5010a1 eligibility response (271) message as depicted in field mapping notes this change may impact real time prescription benefit, electronic prior authorization, etc as this is a change to the eligibility response (271) the bin (iin) and pcn will not be moved or relocated, but the expected formulary identifiers will disclaimer the data in the eligibility response (271) is changing to accommodate formulary ncpdp formulary upgrade (v60+) customers will see this immediately in staging and in production in the future about this overview the formulary ids and eligibility fields overview explains how formulary ids and key eligibility fields are used within surescripts workflows it provides definitions, data requirements, and integration guidelines to help ensure accurate identification of patient coverage and formulary alignment this guide is designed to support vendors and partners in implementing these fields effectively for the formulary version 60 upgrade key identifiers at a glance this table defines each one and notes whether it is a consolidated v3 0 identifier or maps to granular v60 files identifier carried in v3 0 vs v60 role formulary status id ref fo element 2 consolidated in both; must be ≤10 chars for v3 0 translation its ref03 carries the v60 product exclusion (pe) file id coverage list id ref cli element 2 v3 0 consolidated one identifier may back many coverage rules in v60 those rules are split into granular files; ref03 carries the prior authorization (pa) file id copay id ref ig element 2 v3 0 copay identifier in v60 its ref03 carries the pharmacy network (pn) file id; product specific copay moves to the ps msg segment alternatives id ref als element 2 consolidated in both; must be ≤10 chars for v3 0 translation its ref03 carries the v60 step therapy products (st) file id who is affected and how because the formulary identifiers ride in the eligibility response (271), this single change propagates to every downstream transaction that consumes 271 data transaction / workflow who is affected impact of the v60 identifier change eligibility response (271) pbms/payers (send) · ehr/provider vendors (receive) direct change v60 file ids added in ref03 and msg segments alongside the v3 0 ref02 values real time prescription benefit (rtpb) ehr/provider vendors · pbms/payers consumes 271 formulary identifiers; expect the new ref03/msg file ids to flow through electronic prior authorization (epa) ehr/provider vendors · pbms/payers prior authorization file is now identified via ref cli element 3 (pa) in v60 on demand formulary (odf) receiving systems maps a v3 0 only 271 (no ref03/msg) into granular requests — see the odf integration guidance and the absence rule in for pbms / payers populating the 271 docid\ cfuvlnc mqs8p4daac1as document references note this document is meant to support, integrate, and further clarify the standards, implementation guides, and best practices as used through the surescripts network it does not reproduce the base standard in its entirety requirements beyond those in the standard documentation are called out in this document and are also enforceable customers should read and comprehend the associated standards prior to reading this document please reference the following documents when reading this guide surescripts provided materials eligibility companion guide formulary companion guide external materials to be obtained by the customer (available at www ncpdp org http //www ncpdp org ) ncpdp formulary and benefit standard implementation guide (v60 republished may 2024) asc x12n/005010x279a1 health care eligibility benefit inquiry and response (270/271) ncpdp this guide utilizes the ncpdp formulary and benefit standard implementation guide (version v60 republished may 2024) as a baseline to become a member, please go to http //ncpdp org/membership/apply online aspx http //ncpdp org/membership/apply online aspx the ncpdp formulary and benefit standard implementation guide (version v60 republished may 2024) contains a complete list of fields and additional requirements customers should read and comprehend the associated standards prior to reading this guide ncpdp is an american national standards institute (ansi) accredited standard development organization the ncpdp standard is a copyrighted document and may be obtained by contacting ncpdp 9240 e raintree drive scottsdale, az 85260 7518 phone (480) 477 1000 fax (480) 767 1042 http //www ncpdp org http //www ncpdp org/ x12 for sections of this guide pertaining to x12 standards “materials reproduced with the consent of” copyright i 2009, data interchange standards association on behalf of asc x12 format i 2009 washington publishing company all rights reserved users of this guide must purchase their own copy of the asc x12n/005010x279a1 (270/271) and x12n/005010x231a1 (999) as this guide only includes a subset of those guides go to https //x12 org https //x12 org/ to obtain your copy