iPrescribe: What Do Drug Formulary Codes Stand For?

Pharmacy type

Indicates the type of pharmacy to which the formulary information applies

Code Description
LTC Long-term care
MO Mail Order
R Retail
SP Specialty
C EPCS Enabled
E Accepts Electronic Rx
24 Open 24 hours

 

Formulary Status 

Defines whether or not the plan covers a drug and the extent to which the drug is on the plan's list of preferred drugs.

Code Description
F Formulary: this drug is on the plan's formulary list and will be reimbursed to some extent.
NF Non-Formulary: this drug is considered non-formulary. It may have a higher co-pay or may not be reimbursed.
NR Not Reimbursed: this drug is not reimbursed by the plan and the patient will be responsible for the full cost of the medication.

P1 ...

Formulary Preferred: this drug is on the plan's list of preferred drugs. The higher the number after 'P', the more preferred the drug.

U

Unknown: the formulary status of this drug cannot be determined.
*-Note The payer has provided an explanatory note to accompany the formulary status.

 

Benefit Coverage Details

Provides additional information on how the drug is covered by the plan.

Code Description
AL Age Limitations: this drug may only be used in certain populations such as those under 18 years old.
DE Drug Exclusion: this product is excluded from coverage under the prescription drug benefit. Contact the insurance company for more information.
GL Gender Limitation: this drug may only be covered for a specific gender.
PA Prior Authorization: this drug requires prior authorization or approval before this drug will be covered under the prescription drug benefit.
QL Quantity Limitation: the payer limits the maximum allowable supply of medication per co-pay specified by the prescription drug benefit.

RD-

Resource Detail: the payer has provided a link (e.g. Web URL) that may be used to access additional information about a benefit coverage detail item.
SM Step Medication: the payer has specified alternative drugs that should be prescribed before the selected drug will be covered.
ST Step Therapy: this drug will not be reimbursed unless the patient has tried other medications within the therapeutic class or disease class, although, unlike Step Medication, the plan has not specified exactly which drugs must be tried first.
*-Note The payer has provided an explanatory note to accompany a benefit coverage detail item.
Cost-* Relative Cost: the payer indicates the relative cost of the drug on a scale determined by the payer.

 

Copay Details

Indicates the cost of the drug to the patient

Code Description
%, $ Copay Advice: copay may be defined as a flat amount ($), a percentage of the drug's cost (%), or a combination of both.
OOP Out of Pocket: the copay for this drug depends on the amount that the patient has already spent "out of pocket" during the plan period.

T1/3, etc

Copay Tier: the copay tier to which the payer has assigned the drug, shown relative to the highest tier defined for the plan. For most plans, the lower the tier, the lower the copay amount.

CopayNote

The payer has provided an explanatory note to accompany copay details.
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