Business Requirement

Client would like to classify drug in the claim. This information will be further used in the reports for analytics. The classification can be OTCs, Specialty, Administrative or could be a client's custom classification.

Solution

• Plan → Manage Rules → Coverage Rules / Benefit Coverage rule. When adding the covered drugs in the benefit coverage, the appropriate Covered Drug Status code value should be used according to the drug classification.

  
  

  

  
  

• For eg., If you are adding specialty covered drugs, then the covered drug status code should be selected as S - Specialty

• There is a flag for non covered drugs Y - Non Covered Drugs. For eg., A benefit coverage rule that defines that vaccines are not covered can be defined like this.

Note : Exclude condition has to be used in the Criteria to define Non covered drugs. Selecting Covered Drug Status Code as Y - Non Covered Drug does NOT mean the drug in the criteria is not covered in the plan

• We have also new codes which can be used used to classify client's custom drugs. 

• The Covered Drug Status Code is being stamped in the claims today which helps to identify the drug category. The information is captured today in claim_history_drug table

• claim_history_drug.covered_drug_status_code indicates drug status - whether its Specialty Drug or OTC or Non Covered Drug or simple covered drug etc..

Future Enhancements

• Currently the drug status code is just captured and stored for each claim. Currently its not included in any Procella standard extracts and its not currently shown in UI. These enhancements will be done in future.