Coverage Rules - Preferred Drugs & Formulary Compliance

Preferred Drug

Code	Description
NP	Non-Preferred Drug
XP	No-Preferred Drug
P0	Preferred Drug, Tier 0
P1	Preferred Drug, Tier 1
P2	Preferred Drug, Tier 2
P3	Preferred Drug, Tier 3
P4	Preferred Drug, Tier 4
P5	Preferred Drug, Tier 5
P6	Preferred Drug, Tier 6
P7	Preferred Drug, Tier 7
P8	Preferred Drug, Tier 8
P9	Preferred Drug, Tier 9

• After Formulary Status is processed, the Preferred Drug status will be evaluated.
• Below is the flow that the system performs to identify Preferred Drug Status

• Preferred Drug setup is set in plan/manage rules/coverage rules/Preferred Drug. Similar to Adjudication rules, the process is from the top to the bottom of the hierarchy.
• For the Plan level rule, matching is based on criteria specified in the rule.

• Provider Default Level: The provider type of the claim should match the Provider Type specified in the rule for the criteria to be evaluated. 
• Provider Type could be Mail, Retail, Retail 90, Specialty, or Other. (This is assigned based on the identified Network Panel)

• Provider Complex and Exception level: The Provider Network (Provider Group, Provider) of the claim should match the Provider Group/Provider specified in the rule for the criteria to be evaluated

• Formulary Status and Preferred Drug Status are used to identify Formulary Compliance.
• Refer formulary status code here

Formulary Status, Preferred Drug Status, and Formulary Compliance of a claim can be viewed in the Claim History screen / Claim tab