Coverage Rules - Formulary

Below is the logic on how the formulary status is assigned for the drug in the claim

• The Formulary is set in Plan/Manage Rules/Coverage Rules/Formulary section.
• The processing of formularies involves evaluating rules categorized under "Formulary," following a hierarchical order to ensure the prioritization of the most relevant rules. Similar to adjudication rules, processing begins at the top of the benefit hierarchy.

• Plan Default/Exception/Complex Level: At these levels, matching is based on criteria specified in the rule.

Provider Levels:

• 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