| Name | Description | Type | Additional information |
|---|---|---|---|
| PlanPricingGroupsUrl |
Gets or sets the link to the Plan Pricing Groups resource for the plan |
string |
None. |
| CompanyID |
Gets or sets the identifier for the Company |
globally unique identifier |
None. |
| PlanName |
Gets or sets the name given to represent the Plan |
string |
None. |
| Description |
Gets or sets the description given to represent the plan |
string |
None. |
| ValidatePCN |
Gets or sets whether the PCN should match when processing claims |
boolean |
None. |
| NewStartDays |
Gets or sets the number of days that must lapse before drug is considered new. Ex: Setting to 365 days would require the member to have stopped therapy for 365 days before it's considered new therapy again. |
integer |
None. |
| MaxClaimDays |
Gets or sets the maximum number of days the plan allows for submitting a claim based on the date of service |
integer |
None. |
| MaxReversalDays |
Gets or sets the maximum number days the plan allows for reversing a claim |
integer |
None. |
| StandardMessage |
Gets or sets the standard message in the claim header |
string |
None. |
| ApproveMessage |
Gets or sets the approve message in the claim header when claim is paid |
string |
None. |
| RequiredOverrideMessage |
Gets or sets the prior authorization message in the claim header when drug requires a PA |
string |
None. |
| NotCoveredMessage |
Gets or sets the not covered message in the claim header when drug is not covered |
string |
None. |
| OutOfPocketMessage |
Gets or sets the out of pocket message in the claim header when out of pocket limit has been reached |
string |
None. |
| HelpDeskPhoneNumber |
Gets or sets the help desk phone number |
string |
None. |
| UnknownDispenseFee |
Gets or sets the the catch-all dispense fee for the plan |
decimal number |
None. |
| UnknownUseSubmittedDispenseFee |
Gets or sets whether to use the submitted dispense fee for unknown/undefined drugs |
boolean |
None. |
| UnknownUseUsualAndCustomary |
Gets or sets whether to use Usual and Customary for unknown/undefined drugs |
boolean |
None. |
| UnknownUseGrossAmountDue |
Gets or sets whether to use Gross Amount Due for unknown/undefined drugs |
boolean |
None. |
| CompoundPriceSubmittedDrugs |
Gets or sets the whether the plan will price each drug of a compound |
boolean |
None. |
| CompoundRequireValidNDC |
Gets or sets whether a valid NDC must be used in a compound claim |
boolean |
None. |
| CompoundMinimumDrugsToPrice |
Gets or sets the minimum number of drugs to price in the compound |
byte |
None. |
| CompoundMaxDrugsToPrice |
Gets or sets the maximum number of drugs to price in the compound (blank or null means all will be priced) |
byte |
None. |
| CompoundMinimumPrice |
Gets or sets the minimum indgredient cost for the compound |
decimal number |
None. |
| CompoundDefaultFee |
Gets or sets the default dispense fee to be applied for a compound (level of effort 0) |
decimal number |
None. |
| CompoundEffort1Fee |
Gets or sets the dispense fee for level of effort 1 |
decimal number |
None. |
| CompoundEffort2Fee |
Gets or sets the dispense fee for level of effort 2 |
decimal number |
None. |
| CompoundEffort3Fee |
Gets or sets the dispense fee for level of effort 3 |
decimal number |
None. |
| CompoundEffort4Fee |
Gets or sets the dispense fee for level of effort 4 |
decimal number |
None. |
| CompoundEffort5Fee |
Gets or sets the dispense fee for level of effort 5 |
decimal number |
None. |
| CompoundUseSubmittedDispenseFee |
Gets or sets the indicates whether to use the submitted dispense fee from the pharmacy for the compound |
boolean |
None. |
| CompoundUseUsualAndCustomary |
Gets or sets the indicates whether to use the submitted Usual and Customary price from the pharmacy for the compound |
boolean |
None. |
| CompoundUseGrossAmountDue |
Gets or sets the indicates whether to use the Gross Amount Due price from the pharmacy for the compound |
boolean |
None. |
| CompoundDrugPricingUrl |
Gets or sets the link to the Drug Pricing resource for compound drugs |
string |
None. |
| CompoundDrugPricingNo |
Gets or sets the identifier of the special drug pricing for a compound. |
integer |
None. |
| UnknownDrugPricingUrl |
Gets or sets the link to the Drug Pricing resource for unknown/undefined drugs |
string |
None. |
| UnknownDrugPricingNo |
Gets or sets the identifier of the special drug pricing for an unknown/undefined drug. |
integer |
None. |
| UseNetworkCoinsurance |
Gets or sets whether to use Network Coinsurance if available |
boolean |
None. |
| UseNetworkIncentive |
Gets or sets whether to use Network Incentive if available |
boolean |
None. |
| UseNetworkDeductibleOptions |
Gets or set whether to use Network deductible options if available |
boolean |
None. |
| DURDrugDrugCheck |
Gets or sets whether to use Drug-Drug DUR |
boolean |
None. |
| DURDrugDrugLevelSeverity |
Gets or sets the least severe level of DUR the plan enforces |
string |
None. |
| DURDrugDrugMessage |
Gets or sets the message to send in the claim response when severity is exceeded |
string |
None. |
| DURDrugDrugActionTypeNo |
Gets or sets the action to take when severity level threshold is crossed |
integer |
None. |
| MMEActionTypeNo |
Gets or sets the action to take when threshold is exceeded |
integer |
None. |
| MMEThresholdCheck |
Gets or sets whether the system will determine if the patient is exceeding the daily dosage threshold for opioid medications |
boolean |
None. |
| MMEThreshold |
Gets or sets the daily dosage threshold for opioid medications |
integer |
None. |
| MMEResponseMessage |
Gets or sets the message to send in the claim response when MME Threshold is exceeded |
string |
None. |
| AllowFutureDateOfService |
Gets or sets whether the plan allows claims with future date of service |
boolean |
None. |
| DefaultPharmacyTier |
Gets or sets the default pharmacy tier value that will be saved on the claim audit if it isn't specified elsewhere during processing of a claim |
string |
None. |
| ReturnMemberLookupMessages |
Gets or sets whether the eligibility messages are returned when using open enrollment and if the member was either found using an alternate lookup or was added to the system |
boolean |
None. |
| SubscribeToGlobalPricingACI |
Gets or sets whether the plan subscribes to Location/Global ACI pricing |
boolean |
None. |
| SubscribeToGlobalPricingAcqCost |
Gets or sets whether the plan subscribes to Location/Global acquisition pricing |
boolean |
None. |
| SubscribeToGlobalPricingCustomMAC |
Gets or sets whether the plan subscribes to Location/Global Custom MAC pricing |
boolean |
None. |
| SubscribeToGlobalPricingRefPrice |
Gets or sets whether the plan subscribes to Location/Global reference pricing |
boolean |
None. |
| RxExpireDays |
Gets or sets the number of days to indicate that a prescription is "expired." An Rx is expired if the date of service is later than the first fill for the Rx plus the RxExpireDays. |
integer |
None. |
| PrescriberGraceDays |
Gets or sets the Prescriber Grace Days to be used in conjuction with prescriber effective dates in rules. If a prescriber's effective date has expired, but the grace period has not been exceeded, the claim will continue processing. |
integer |
None. |
| EligibilityRejectMessage |
Get or sets the message for eligibility rejects |
string |
None. |
| RejectClaimIfNoCustomPrice |
Gets or sets whether claims should reject if there is no custom pricing |
boolean |
None. |
| PrescriptionWrittenMaxDays |
Gets or sets the Prescription Written Max Days |
integer |
None. |
| Url |
Gets or sets the link representing a link back to the resource |
string |
None. |
| ID |
Gets or sets the identifier for the resource |
integer |
None. |