There are 4 options in the Group Plan association screen:

Reject is a fairly simple check. When we do drug eligibility and the claim is for a compound code = 2, then we should reject the claim. 

Pay will have two processes.

• The first one happens in drug eligibility. At least one ingredient in the compound has to be covered and that ingredient should be a Legend drug, then we will allow the claim to move forward. 
• When we get to ingredient pricing, we will price ALL drugs (ingredients) in the compound.

Bypass will have two processes.

• The first one happens in drug eligibility. At least one ingredient in the compound has to be covered and that ingredient should be a Legend drug, then we will allow the claim to move forward. 
• When we get to ingredient pricing, we will price ONLY COVERED drugs (ingredients) in the compound.

Deny - When we first get the claim, we will DENY the claim and require a Prior Authorization to continue processing. If the PA exist in the system, then we process the claim as if it were the Pay - Single Drug option.

What is Legend Drug?  A Legend drug is thedrug  RX OTC INDICATOR as either R or S (not O or P)

Dispensing Fee Method

There is a Dispensing Fee Method option available in the Group Plan association screen the define how the dispensing fee should be calculated for a compound claim.

• Total of all Dispensing Fees - This will calculate the dispensing fee of the covered or all ingredients based on the Compound coverage. The total will be the dispensing fee of the claim.
• Highest Dispensing Fee - This will calculate the dispensing fee of the covered or all ingredients based on the Compound coverage. The highest will be taken as the dispensing fee of the claim
• Lowest Dispensing Fee - This will calculate the dispensing fee of the covered or all ingredients based on the Compound coverage. The lowest will be taken as the dispensing fee of the claim

Compound Brand Class

In the Plan setting, there is an option to define the brand class for compounds.

• PART D:  Medicare Part D Rule 
• HIGH IC:  Brand Class of Highest Ingredient Cost of Legend Drug
• LOW IC:  Brand Class of the Lowest Ingredient Cost
• Brand SS:  Brand Single Source
• Brand MS:  Brand Multi Source
• Generic SS:  Generic Single Source
• Generic MS:  Generic Multi Source
• Default 

Compound Price Compare

• The above comparison setting is available in the Plan configuration and Provider Network configuration. Based on the pricing setup, the comparison will be applied accordingly

• If the toggles are ON, the calculated Compound pricing will be compared to enabled parameters and the lowest amount will be taken as the final price.
• Compound Pricing
  • Compound Pricing = Ingredient Cost + Dispensing Fee + Sales Tax
  • Compound Ingredient Cost and Dispensing will be calculated based on the Group Plan setting. The compound coverage in the group plan association screen decides whether to calculate cost of all ingredients or covered ingredients
  • The Dispensing Fee Method decides the dispensing fee of the claim.

Lesser of Submitted Ingredient Cost has not been handled today and it will implemented in the future