EDIT - Program Admin Fee

The Program Administration Fee (PAF) is a fee used for any multitude of business reasons.  The fee can be for any reason.  The PAF has special calculations which allow for the total cost of the prescription plus the fee do not exceed the Usual and Customary U&C) and Gross Amount Due (GAD) on the claim.

Edit Name is the unique name for the edit.

PAF Fee Method Type defines the type of fee to calculate.

• Variable:  The option will process the Program Admin Fee but reduce the fee amount if it exceeds the U&C and/or GAD.
• Full Admin Fee Only:  Only apply a fee if a full PAF fee is calculated.
• Always Fee:  Always apply a fee regardless of the U&C and GAD on the claim.

Compare to Lower of allows the Program Admin Fee, as added to the Total Rx Cost, to be less than the U&C, GAD, or U&C and GAD.

Cost Sharing Method Type identifies who will be financially liable for the Program Admin Fee.  The fee can then be charged to the Member or the Plan.

The U&C/GAD Floor is the minimum at which a PAF is not calculated for a claim.  This is to account for pharmacy fixed dollar, low-cost Rx programs such as a $4.00 generic program or minimum rx cost requirements. 

Add to Claim Response Field Type indicates where in the claim the PAF Fee is populated. 

• Dispensing Fee Paid
• Amount Attributable to Processor Fee

For most plan designs, it will be in the Amount Attributable to Processor Fee as the fee may be recouped from the Pharmacy Payment, typical if the amount is paid by the Member.  Regardless of which field is selected, the fee is tracked independently.

Message Group is the assigned Message group to be captured each time the edit is used.

 

Range

Each of the following fields are available for each range.   Only 1 range is required.  No gaps in range are allowed and the last range must have a Range End of 9999999.99.

Range Start:  This is the beginning Rx Cost for the range.

Range End:  This is the maximum Rx Cost for the range. 

Min Program Fee: Min program fee below which the PAF will not be collected.

Program Fee:  The Program Admin Fee to be collected.

U&C/GAD Offset Method Type:  The U&C/GAD Offset is a modification of the submitted U&C.  This enables the Sponsor to manage the difference between the Total Rx Cost with PAF vs the submitted U&C/GAD.  This offset can be a fixed dollar amount or a percentage amount. 

• Fixed $ Amount:  Use a fixed amount to offset from the U&C/GAD.
• % Amount:  Use a percentage to offset from the U&C/GAD.

Fixed $ Amount is the amount to offset from the U&C/GAD.

Fixed % Amount is the percentage amount offset from U&C/GAD.

Min $ Offset for Fixed %:  The minimum dollar amount for a percentage offset.  This is available only when Fixed % Amount is used.

Max $ Offset for Fixed %: The maximum dollar amount for a percentage offset.  This is available only when Fixed % Amount is used.

 

NOTE: The U&C/GAD Offset percentage is based on/calculated on the submitted U&C/GAD Amount.