Medco Version 5.1 Payer Sheet January 2006 Use when submitting ...

Medco Health Solutions, Inc.100 Parsons Pond DriveFranklin Lakes, NJ 07417www.medco.com/rph1 800-922-1557556-AUPreferred Product DescriptionResponse Pricing Segment: OptionalField # NCPDP Field Name NCPDP Values Supported by MedcoMandatory /Optional111-AM Segment Identification 23 M5Ø5-F5 Patient Pay Amount M5Ø6-F6 Ingredient Cost Paid M5Ø7-F7 Dispensing Fee Paid M558-AW559-AX56∅-AY561-AZ521-FLFlat Sales Tax Amount PaidPercentage Sales Tax Amount PaidPercentage Sales Tax Rate PaidPercentage Sales Tax Basis PaidIncentive Fee Amount Paid5Ø9-F9 Total Amount Paid M566-J5 Other Payer amount paid recognized522-FM Basis of Reimbursement Determination M523-FN512-FC513-FD514-FE517-FH518-FI519-FJ52Ø-FKAmount Attributed to Sales TaxAccumulated Deductible AmountRemaining Deductible AmountRemaining Benefit AmountAmount Applied to Periodic DeductibleAmount of Copay/CoinsuranceAmount Attributed to Product SelectionAmount Exceeding Periodic Benefit Maximum346-HH Basis of Calculation – Dispensing Fee Not supported Partial Fill347-HJ Basis of Calculation – Copay Not supported Partial Fill348-HK Basis of Calculation – Flat Sales Tax Not supported Partial Fill349-HM Basis of Calculation – Percentage Sales Tax Not supported Partial FillResponse Transaction (cont): Response DUR/PPS Segment: OptionalField # NCPDP Field Name NCPDP Values Supported by MedcoMandatory /Optional111-AM Segment Identification 08 M567-J6 DUR/PPS Response Code Counter Up to 9 occurrences439-E4 Reason for Service Code528-FSClinical Significance Code7