Formulary Status and Preference Level

formulary status formulary status is the status of the drug within the formulary this field represents the general amount of payment assistance the insurance provides for a medication formulary status is used in formulary status detail, copay summary file detail, and product exclusion file detail reference see formulary and benefit implementation guide version 60 sec 4 2 1 page 16 for more information additional guidance determining the best record between brand preferred (b) and on formulary/preferred (p) if records containing b and p formulary status values have different preference levels, the record with the lower preference level is considered to be better however; the record with the p value is considered to be better than one containing b when preference level values of the two records are the same, or preference level is not populated in either record value descriptions value description “best” rollup ranking 1 = best “best” roll up rationale z zero dollar copay this medication does not have a copay the cost is $0 to the patient 1 no cost to the patient p or b note august 2024 this section was changed based on discussion in the ncpdp formulary & benefit task group and development of the v63 f\&b version and examples guide on formulary/preferred (p) has a higher rollup ranking than brand preferred if the records have equal preference levels the medication is the preferred payable products in that patient's plan formulary brand preferred (b) indicates the payer prefers the brand over the generic 2 / 3 see determining the best record between brand preferred (b) and on formulary / preferred (p) above o on formulary the medication submitted is included in the list of payable products in that patient's plan formulary but that there may be a more preferred product in the therapeutic category 4 on the formulary but not preferred n non formulary response code indicating that the prescribed drug is not included in the plan formulary 5 not in the formulary, but covered to some extent x non reimbursable without authorization this medication is not covered although an exception or appeal process may exist 6 product might be covered y non reimbursable the medication will never be reimbursable by the payer with no appeal process 7 product is never covered c carve out this medication is processed by a third party, not the payer providing the formulary 8 is a more informational form of “unknown” u unknown (all versions) 9 any other value is more informational preference level if there are multiple alternatives for a given source drug, preference level is the payer's order of preference (a lower number equals greater preference) preference level is used in formulary status detail, alternative product groups detail, and step therapy product groups detail reference see formulary and benefit implementation guide version 60 sec 4 2 1 page 17 for more information per the formulary and benefit implementation guide version 60 the numeric preference level provides additional detail within the same formulary status formulary status is determined by using the formulary status value and preference level combination products with a higher preference level with the same formulary status are considered less preferable by the payer; those with a lower status are more preferable treat all non listed defaults with a formulary status preference level of “100” and do not display this value they will have a very low preference compared to explicitly listed values with a preference level use of preference level in formulary status list rollup preference level serves as a secondary factor when determining the “best” formulary status list record (after the formulary status value) if multiple input records have the same formulary status but different preference levels, the record with the lowest preference level is the “best” and is included in the rolled up list value descriptions value description “best” rollup ranking 1 = best 1 most preferred (v60) 1 2 98 ordered preference between least to most (v60) 2 98 99 least preferred (v60) 99