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

Response Pricing SegmentSegment Identification (111-AM)= “23”Field # NCPDP Field Name Value PayerUsageMedco100 Parsons Pond DriveFranklin Lakes, NJ 07417Claim BillingAccepted/Paid (or Duplicate ofPaid)Payer Situation394-MW BENEFIT STAGE AMOUNT R Imp Guide: Required when aMedicare Part D payer appliesfinancial amounts to Medicare PartD beneficiary benefit stages. Thisfield is required when the plan is aparticipant in a Medicare Part Dprogram that requires reporting ofbenefit stage specific financialamounts.Required if necessary forstate/federal/regulatory agencyprograms.Payer Requirement: Amount willbe returned as appropriate for thecorresponding Benefit StageQualifiers (393-MV).577-G3 ESTIMATED GENERIC SAVINGS RW Imp Guide: This information shouldbe provided when a patient selectedthe brand drug and a generic form ofthe drug was available. It will containan estimate of the differencebetween the cost of the brand drugand the generic drug, when thebrand drug is more expensive thanthe generic.128-UCSPENDING ACCOUNT AMOUNTREMAININGRWImp Guide: This dollar amount willbe provided, if known, to thereceiver when the transaction hadspending account dollars reportedas part of the patient pay amount.129-UDHEALTH PLAN-FUNDEDASSISTANCE AMOUNTRWImp Guide: Required when thepatient meets the plan-fundedassistance criteria, to reduce PatientPay Amount (5Ø5-F5). The resultingPatient Pay Amount (5Ø5-F5) mustbe greater than or equal to zero.133-UJAMOUNT ATTRIBUTED TOPROVIDER NETWORKSELECTIONRWImp Guide: Required if Patient PayAmount (5Ø5-F5) includes anamount that is attributable to a costshare differential due to theselection of one pharmacy overanother.134-UKAMOUNT ATTRIBUTED TOPRODUCT SELECTION/BRANDDRUGRWImp Guide: Required if Patient PayAmount (5Ø5-F5) includes anamount that is attributable to apatient’s selection of a Brand drug.“Materials Reproduced With the Consent of©National Council for Prescription Drug Programs, Inc.2008 NCPDP”19