Medco Version D.0 Medicare Part D Payer Sheet - Express Scripts

Medco100 Parsons Pond DriveFranklin Lakes, NJ 07417Response Pricing SegmentSegment Identification (111-AM)= “23”Field # NCPDP Field Name Value PayerUsage559-AX PERCENTAGE SALES TAXRWAMOUNT PAIDClaim BillingAccepted/Paid (or Duplicate ofPaid)Payer SituationImp Guide: Required if this value isused to arrive at the finalreimbursement.Required if Percentage Sales TaxAmount Submitted (482-GE) isgreater than zero (Ø).Required if Percentage Sales TaxRate Paid (56Ø-AY) and PercentageSales Tax Basis Paid (561-AZ) areused.56Ø-AYPERCENTAGE SALES TAX RATEPAIDRWImp Guide: Required if PercentageSales Tax Amount Paid (559-AX) isgreater than zero (Ø).561-AZPERCENTAGE SALES TAX BASISPAIDRWImp Guide: Required if PercentageSales Tax Amount Paid (559-AX) isgreater than zero (Ø).521-FL INCENTIVE AMOUNT PAID RW Imp Guide: Required if this value isused to arrive at the finalreimbursement.Required if Incentive AmountSubmitted (438-E3) is greater thanzero (Ø).5Ø9-F9 TOTAL AMOUNT PAID R522-FM BASIS OF REIMBURSEMENTRDETERMINATIONImp Guide: Required if IngredientCost Paid (5Ø6-F6) is greater thanzero (Ø).523-FNAMOUNT ATTRIBUTED TOSALES TAXRWRequired if Basis of CostDetermination (432-DN) is submittedon billing.Imp Guide: Required if Patient PayAmount (5Ø5-F5) includes sales taxthat is the financial responsibility ofthe member but is not also includedin any of the other fields that add upto Patient Pay Amount.Imp Guide: Provided forinformational purposes only.Imp Guide: Provided forinformational purposes only.512-FC ACCUMULATED DEDUCTIBLEAMOUNTRW513-FD REMAINING DEDUCTIBLERWAMOUNT514-FE REMAINING BENEFIT AMOUNT RW Imp Guide: Provided forinformational purposes only.517-FH AMOUNT APPLIED TO PERIODICRWDEDUCTIBLEImp Guide: Required if Patient PayAmount (5Ø5-F5) includesdeductible.“Materials Reproduced With the Consent of©National Council for Prescription Drug Programs, Inc.2008 NCPDP”16