Procella HelpdeskThe Copay/Coinsurance edit sets up the method to calculate the member copay/coinsurance responsibility. From a definition perspective, a Copay is a Flat Amount. If there is a percent involved in the calculation, it is technically Coinsurance.
Throughout the documentation, copay, copay/coinsurance, cost share, and coinsurance tend to be used interchangeably.
The difference between the Fixed and Tiered Cost Share Types are simple. Fixed is only one range while Tiered allows for different copay calculations by one or more ranges.
The top section of the copay edit identifies the Edit Name entered. This must be unique within the edits.
The Cost Share Type is greyed out as it was selected in the prior screen. If the selection is in error, simply click on the link above the edit name. All information in the edit, except for edit name, will be reset.
The Sharing Basis is only available on the Tiered Cost Share Type. The Sharing Basis is what is used for the ranges. The predominant Sharing Basis will be Days Supply. As an example, the copay is $15.00 for a days supply of 0 through 30 and $40.00 for 31 through 999.
The Claim Type indicates if the Copay should be applied to all claims, POS only claims or DMR claims only.
The Basis of Calculation is there if needed, but if in doubt, leave it as the Quantity Dispensed.
The Processing option allows the result of the edit to be excluded (unchecked) or included (checked) in the Plan Default Accumulations. If checked, any amounts accumulated at the rule level will be accumulated at the PLAN DEFAULT level. Checked or unchecked, the rule will only use its accumulation to decide the range for copay calculation.
Ranges, as noted above, are used for Tiered Copay edits. Establish the ranges needed. Use the + ADD ANOTHER RANGE button on the bottom of the screen as needed.
Below is a screen shot of one range. The important elements are highlighted.
Range Start and Range Stop are the start and end values for the Range. In the screen above, the range starts at 0 days supply and ends at 30 days supply. The last range must have a Range Stop of its maximum. For Days Supply, the maximum for Range Stop is 999.
Type: This identifies the type of copay/coinsurance to applied for the Brand Class.
- Flat Amount: This is a fixed, flat dollar amount.
- Percentage: This is a percentage and is based on the total calculated cost of the prescription.
- Both: This allows the use of both a flat and percentage amount when calculating the copay/coinsurance.
- Neither: This option effectively sets up a zero copay.
Flat Amount: A Flat Amount is simply a flat dollar amount set for the copay.
Percentage: A Percentage is the percent representing the coinsurance.
Minimum: The minimum charge for a Cost Share. Available only on Percentage
Maximum: The maximum charge for a Cost Share.
Calculation: This allows control over how the flat and percentage calculations are performed.
- % then $: This process takes the Percentage multiplied against the Rx Cost and then adds the Flat Amount.
- $ then %: This subtracts the flat amount from the total Rx Cost and then applies the percentage calculation against the balance. The Flat Amount is then added to the Percentage Calculation for the final Copay/Coinsurance.
- Less than $ or %: This option takes the lower amount between the Flat Amount ($) and the Percentage Amount (%).
- Greater than $ or %: This option takes the higher amount between the Flat Amount ($) and the Percentage Amount (%).
Sample Copay
Below is a varied copay/coinsurance setup and will be set in a FIXED Cost Share Type
The Total Rx Cost for the examples is $100.00.
Default Copay
The Default Copay is setup as a Flat $25.00. Any claim hitting the default rule will calculate out a $25.00 copay.
Brand SS
The Brand Single Source is setup as a Percentage Coinsurance of 20.50% with a Minimum Amount of $10.00 and a Maximum of $10,000.
The calculated claim has a copay of $20.50, or .2050 * 100.00 = $20.50. As this is greater than the minimum and less than the maximum, no other adjustment is made.
Brand MS
The Brand Multi Source is setup as Both, using both the flat amount ($25.00) and percentage amount (20.50%) with a Minimum of $10.00, a Maximum of $10,000, while using the % then $ calculation method.
The calculation is:
$100.00 * 0.2050 = $20.50 (percent amount)
$20.50 + $25.00 = $45.50 (flat amount)
As the calculated copay is within the minimum and maximum, no adjustments are required.
Generic SS
The Generic Single Source is setup as Both, using both the flat amount ($15.00) and percentage amount (10.00%) with a Minimum of $10.00, a Maximum of $50.00, while using the $ then % calculation method.
The calculation is:
$100.00 - $15.00 = $ 85.00 (flat amount)
$ 85.00 * 0.1000 = $ 8.50 (percentage amount)
$ 8.50 + $15.00 = $ 23.50 (flat + percentage)
As the calculated copay is within the minimum and maximum, No adjustments are required.