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 Payer393-MV BENEFIT STAGE QUALIFIER Blank = Not specifiedØ1 = DeductibleØ2 = Initial BenefitØ3 = Coverage Gap (donuthole)Ø4 = Catastrophic Coverage5Ø = Not paid under Part D,Paid Under Part C benefit (forMA-PD plan)6Ø = Not paid under Part D,paid as or under asupplemental benefit only.*61 = Part D drug not paid byPart D plan benefit. Paid as orunder a co-administeredbenefit only.**62 = Non-Part D/non-qualifieddrug not paid by Part D planbenefit. Paid as or under a coadministeredbenefit only.**7Ø = Part D drug not paid byPart D plan benefit, paid by thebeneficiary under plansponsorednegotiated pricing8Ø = Non-Part D/non-qualifieddrug not paid by Part D planbenefit, hospice benefit or anyother component of Medicare;paid by the beneficiary underplan-sponsored negotiatedpricing9Ø = Enhance or OTC drug(PDE value of E/O) notapplicable to Part D drugspend, but covered by Part Dplan***(Occurs up to 4 times)UsageRClaim BillingAccepted/Paid (or Duplicate ofPaid)Payer SituationImp Guide: Required if BenefitStage Amount (394-MW) is used.Payer Requirement: See values“Materials Reproduced With the Consent of©National Council for Prescription Drug Programs, Inc.2008 NCPDP”18