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

Medco100 Parsons Pond DriveFranklin Lakes, NJ 07417Pricing SegmentSegment Identification (111-AM) =“11”Field # NCPDP Field Name Value PayerUsage482-GE PERCENTAGE SALES TAX AMOUNTRWSUBMITTEDClaim BillingPayer SituationImp Guide: Required if its value hasan effect on the Gross Amount Due(43Ø-DU) calculation.483-HEPERCENTAGE SALES TAX RATESUBMITTEDRWImp Guide: Required if PercentageSales Tax Amount Submitted (482-GE) and Percentage Sales Tax BasisSubmitted (484-JE) are used.Required if this field could result indifferent pricing.Required if needed to calculatePercentage Sales Tax Amount Paid(559-AX).484-JEPERCENTAGE SALES TAX BASISSUBMITTEDRWImp Guide: Required if PercentageSales Tax Amount Submitted (482-GE) and Percentage Sales Tax RateSubmitted (483-HE) are used.Required if this field could result indifferent pricing.Required if needed to calculatePercentage Sales Tax Amount Paid(559-AX).426-DQ USUAL AND CUSTOMARY CHARGE R Imp Guide: Required if needed pertrading partner agreement.43Ø-DU GROSS AMOUNT DUE R423-DN BASIS OF COST DETERMINATION R Imp Guide: Required if needed forreceiver claim/encounter adjudication.Payer Requirement: Basis of CostDetermination not required for MultiIngredient Compound claims.Prescriber Segment Questions Check Claim BillingIf Situational, Payer SituationThis Segment is always sentXThis Segment is situational“Materials Reproduced With the Consent of©National Council for Prescription Drug Programs, Inc.2008 NCPDP”7