Attachment 2 Medco Balance Inquiry Payer Sheet January 2010 To ...

Response Transaction (cont.):Response Pricing Segment: OptionalField # NCPDP Field Name NCPDP Values Supported by Medco Mandatory /Optional111-AM Segment Identification 23 M5Ø5-F5 Patient Pay Amount M5Ø6-F6 Ingredient Cost Paid M5Ø7-F7 Dispensing Fee Paid M558-AW Flat Sales Tax Amount Paid559-AX Percentage Sales Tax Amount Paid56-AY Percentage Sales Tax Rate Paid561-AZ Percentage Sales Tax Basis Paid521-FL Incentive Fee Amount Paid5Ø9-F9 Total Amount Paid M522-FM Basis of Reimbursement Determination M523-FN Amount Attributed to Sales Tax512-FC Accumulated Deductible Amount513-FD Remaining Deductible Amount514-FE Remaining Benefit Amount517-FH Amount Applied to Periodic Deductible518-FI Amount of Copay/Coinsurance519-FJ Amount Attributed to Product Selection52Ø-FK Amount Exceeding Periodic Benefit Maximum566-J5 Other Amount Paid Recognized COB only346-HH Basis of Calculation – Dispensing Fee Partial Fill347-HJ Basis of Calculation – Copay Partial Fill348-HK Basis of Calculation – Flat Sales Tax Partial Fill349-HM Basis of Calculation – Percentage Sales Tax Partial FillResponse DUR/PPS Segment: OptionalField # NCPDP Field Name NCPDP Values Supported by Medco Mandatory /Optional111-AM Segment Identification 08 M567-J6 DUR/PPS Response Code Counter Up to 9 occurrences439-E4 Reason for Service Code528-FS Clinical Significance Code529-FT Other Pharmacy Indicator53Ø-FU Previous Date of Fill531-FV Quantity of Previous Fill532-FW Database Indicator544-FY DUR Free Text MessagePage 8 of 9