Formulary Data Load

note on demand formulary could be used in lieu of formulary download for on demand formulary, the processing of the formulary load files is processed on the customer’s behalf formulary and benefit summary information model reference this information model is based off the information model in the formulary and benefit implementation guide version 60 see formulary and benefit implementation guide version 60 sec 4 1 page 14 for more information roll up for pbm/payers formulary roll up is the process of combining multiple ndcs into their representative ndc to reduce burden among provider vendor partners the roll up process reduces the file size and therefore reduces the time to access the formulary data pbm/payers provide formulary files at the ndc 11 packaged medication level all prescriber vendors prescribe at a dispensable medication level (medication name, strength, and form) in order to display formulary correctly, the data must be rolled up to a dispensable medication level surescripts performs this roll up feature before the data is supplied to the provider vendor surescripts determines a representative ndc and rolls all formulary information to this level notes if multiple ndcs have differing formulary status, but fall under the same representative ndc, the representative ndc will take the highest formulary status during the roll up process the formulary roll up process will be applied to formulary and benefit version 3 0 and higher formulary roll up process flow if applicable, an exception report will also be created 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 are made available to the pbm/payer in a csv file for periodic download and review the pbm/payer sends in formulary files surescripts processes the file and determines the representative ndcs using supported drug compendia surescripts rolls up all ndcs to the appropriate representative ndc chosen in step 2 surescripts creates a response file upon request that show data that needs to be reviewed see formulary and benefit file validation (for pbm/payers) docid\ x2oyfl6fp4m4mzamlufik for more information note if needed, a roll up exception report based on the file analysis may also be created if this report is needed, it will be made available in the same location as the response file surescripts makes the rolled up data available to the prescriber vendors prescriber vendors download a version of the formulary data that was rolled up using prescriber vendors' contracted drug compendia file processing guidance reference see formulary and benefit implementation guide version 60 sec 5 page 21 for more information formulary and benefit data load roles surescripts, pbm/payers, and provider vendors have the following roles within the formulary and benefit data load process pbm/payer within the formulary and benefit data load process, pbm/payers load and maintain updated formulary information (formulary status, copay, coverage factors, and alternatives) at surescripts provider vendor provider vendors download the formulary information from the surescripts rest api server and integrate it into their point of care application with this information, prescribers can check a prescription drug against a patient’s formulary, view coverage/copay limitations, and consider alternative medications surescripts surescripts’ role in the formulary and benefit data load process is to facilitate the distribution of formulary and benefit files between the pbm/payers and provider vendors document and communicate the formulary and benefit data load specification, process, and usage guidelines validate the formulary and benefit files against the current surescripts specification certify the provider vendor's retrieval of the formulary and benefit files formulary and benefit data load process (for pbm/payers) the formulary and benefit data load consists of two processes formulary publishing (data setup and loading) and formulary retrieval (data integration and presentation to prescribers) formulary and benefit data setup and loading the pbm/payer develops their formulary and benefit file layout according to surescripts’ standard formulary and benefit data load specification the pbm/payer sends surescripts a formulary and benefit file on a defined schedule that contains one or more of the formulary and benefit file types (e g , formulary status and/or alternatives) the formulary and benefit data is electronically transmitted to surescripts via the selected file transfer method as a single physical file surescripts performs a validation of the file surescripts sends the formulary response file back to the pmb/payer indicating the formulary and benefit data load status the response file indicates any errors encountered in the load process surescripts separates the file into individual formulary and benefit files, processing each with its own file identifier depending on the errors encountered during processing, it may prevent the data from loading into the database formulary and benefit data integration and presentation to prescribers (for provider vendors) based on customer to customer contract relationships and the permissions granted by the pbm/payer, surescripts makes the appropriate subset of formulary and benefit files available to download from surescripts the provider vendor checks the rest api on a scheduled basis to determine if there are new or updated formulary and benefit lists available the provider vendor downloads the formulary and benefit lists to their system and makes them available to prescribers via their point of care application during or before a patient’s office visit, a prescriber sends an eligibility request (270) to verify the patient’s health plan information, prescription benefit, and formulary information the request is routed through the system application to surescripts’ master patient index (mpi) for processing, and then on to respective pbm/payer(s) for processing the patient’s formulary ids are contained within the eligibility response (271) sent back from the pbm/payer(s) to surescripts surescripts sends the eligibility response (271) with formulary and alternative id information to the provider vendor the point of care application links these ids from the patient’s eligibility response (271) with the corresponding lists note during the prescribing process, the physician views patient formulary and benefit information within the point of care application to verify that a particular medication is on the patient’s formulary and covered under the patient’s plan additionally, the prescriber can view “preferred” alternative medications within that medication’s therapeutic class formulary and benefit publishing (for pbm/payers) the following sections describe how pbm/payers develop, set up, and load their formulary and benefit files for processing at surescripts file processing options pbm/payers specify within the formulary and benefit file header how data should be processed the options for the formulary and benefit file are “u” (updates) or “f” (full formulary replace) or “d” (file deletion) support of the file deletion option is a necessary enhancement to allow for accurate formulary management note by default, surescripts will share all pbm/payer data; however, if requested by the pbm, surescripts can limit access to data by provider vendor customer update process after receiving the formulary and benefit files from the pbm/payer, surescripts checks each section of the file to validate that the data is formatted correctly if any of the files were previously loaded in the database, the new files replace the existing ones, thereby updating the information any new information not previously loaded in the database is added updates will be processed even if the file contains validation errors this process is outlined in the reject code summary when a pbm/payer would like to notify its partners of the discontinuation of a file, they send an action code of “d” (delete) within the header and include no detail rows in the file when downloading, provider vendors should always compare their files to those available at surescripts and update their records accordingly note if the pbm/payer wants the provider vendor to be notified of the delete, they cannot remove access to the deleted file within the distribution list full replace process with the full replace process, the new formulary and benefit file overwrites all the previously loaded files from the pbm/payer full loads will be processed even if the file contains validation errors this process is outlined in the reject code summary below full replace option should only be used when all file types can be sent to surescripts in one physical file any formulary and benefit file previously loaded in the database that is not included in the new file is purged from the system environment setup before sending formulary and benefit files to surescripts, pbm/payers need to set up a network connection to surescripts and implement the selected file transfer method within their environment the network connection is set up and configured as part of the regular integration process with surescripts for more information, refer to the secure file transfer docid 5l md1joxwpua 3sonz8 formulary and benefit file naming and structure the pbm/payer’s data load can be made up of several file types surescripts stores these individually, as separate files, to give the provider vendor the ability to select the formulary status, alternative, coverage or copay file applicable to a specific patient the structure of these lists as they appear to the provider vendor is described below file naming the individual formulary and benefit files are named according to the value specified within the formulary and benefit file header (the “formulary id” field) the field is a text field; it can only contain the following characters (a z, a z, numeral 0 9, period “ ”, and a dash “ “) this also applies to alternative id, coverage id, and copay id as these fields are also used to create file names the formulary id can be up to 10 characters long the file names are tied to each participant’s id; therefore, if two pbm/payers use the same file name, the participant id is what distinguishes them within the system notes during the transition period, due to the previous standards formulary coverage and copay identifiers allowing special characters, those translated files may include characters outside of the approved v60 file naming character set this is to ensure support for vendors migrating to the upgrade provider vendor customers will need to ensure they allow processing for these characters underscores are not allowed in the file id portion of the file name formulary retrieval (for provider vendors) surescripts uses a rest api to enable provider vendors to retrieve formulary files the api supports both the ncpdp formulary & benefit version 3 0 as well as version 60 (republished may 2024),and enables the vendor system to retrieve available formulary sources and file types search for formulary files based on source pbm/payer, file type, and load and modified dates download located files for more information, refer to the surescripts formulary file download api overview