| Name | Description | Type | Additional information |
|---|---|---|---|
| EndProcessing |
Gets or sets whether more benefit rules are processed if all criteria has been met |
boolean |
None. |
| SpecialCoinsuranceUrl |
Gets or sets the link to the coinsurance resource for the rule |
string |
None. |
| SpecialCoinsuranceNo |
Gets or sets the identifier for the coinsurance |
integer |
None. |
| SpecialOutOfPocketCoinsuranceUrl |
Gets or sets the link to the out of pocket coinsurance resource for the rule |
string |
None. |
| SpecialOutOfPocketCoinsuranceNo |
Gets or sets the identifier for the out of pocket coinsurance |
integer |
None. |
| SpecialPlanBenefitLimitMonthUrl |
Gets or sets the link to the monthly plan benefit limit resource for the rule |
string |
None. |
| SpecialPlanBenefitLimitMonthNo |
Gets or sets the monthly plan benefit limit identifier |
integer |
None. |
| SpecialPlanBenefitLimitPeriodUrl |
Gets or sets the link to the periodic plan benefit limit resource for the rule |
string |
None. |
| SpecialPlanBenefitLimitPeriodNo |
Gets or sets the periodic plan benefit limit identifier |
integer |
None. |
| SpecialPlanBenefitLimitLifeUrl |
Gets or sets the link to the lifetime plan benefit limit resource for the rule |
string |
None. |
| SpecialPlanBenefitLimitLifeNo |
Gets or sets the lifetime plan benefit limit identifier |
integer |
None. |
| SpecialPlanBenefitLimitRxOnlyMonthUrl |
Gets or sets the link to the Rx only monthly plan benefit limit resource |
string |
None. |
| SpecialPlanBenefitLimitRxOnlyMonthNo |
Gets or sets the Rx only monthly plan benefit limit identifier |
integer |
None. |
| SpecialPlanBenefitLimitRxOnlyPeriodUrl |
Gets or sets the link to the Rx only periodic plan benefit limit resource |
string |
None. |
| SpecialPlanBenefitLimitRxOnlyPeriodNo |
Gets or sets the Rx only periodic plan benefit limit identifier |
integer |
None. |
| SpecialPlanBenefitLimitRxOnlyLifeUrl |
Gets or sets the link to the Rx only lifetime plan benefit limit resource |
string |
None. |
| SpecialPlanBenefitLimitRxOnlyLifeNo |
Gets or sets the Rx only lifetime plan benefit limit identifier |
integer |
None. |
| SpecialMaxPlanPaidAmount |
Gets or sets whether the max amount that can be applied as the plan responsibility for special drugs (takes priority over the patient pay limit). Amounts in excess of the cap will be added to the copay. |
decimal number |
None. |
| SpecialMaxPatientPayAmt |
Gets or sets whether the max amount that can be applied as the patient responsibility for special drugs |
decimal number |
None. |
| SpecialMaxPatientPayAmtIncludeDrugSelPenalty |
Gets or sets whether the drug selection penalties are included in the limit(only applies if an amount is defined) |
boolean |
None. |
| SpecialMaxPatientPayAmtIncludeMemberClaimFee |
Gets or sets whether the member claim fees are included in the limit(only applies if an amount is defined) |
boolean |
None. |
| SpecialExemptFromDeductible |
Gets or sets whether the rule marks claim as exempt from the deductible |
boolean |
None. |
| SpecialExemptFromOutOfPocketLimit |
Gets or sets whether the rule marks claim as exempt from max out of pocket limits |
boolean |
None. |
| SpecialApplyCoinsuranceAsDeductible |
Gets or sets whether the rule applies coinsurance/copay amounts as the deductible amount(even if exempt from deductible) |
boolean |
None. |
| SpecialDeductibleSplit |
Gets or sets whether the percent of the deductible to be paid by the plan |
decimal number |
None. |
| SpecialIncentiveSplit |
Gets or sets whether the percent of the incentive that was added to the drug cost to be paid by the plan (This is not the plan incentive) |
decimal number |
None. |
| SpecialPlanIncentiveUrl |
Gets or sets the link back to the incentive resource for special drugs for the rule |
string |
None. |
| SpecialPlanIncentiveNo |
Gets or sets the plan incentive identifier for special drugs |
integer |
None. |
| SpecialPeriodDeductibleUrl |
Gets or sets the link to the periodic deductible resource for the rule |
string |
None. |
| SpecialPeriodDeductibleNo |
Gets or sets the periodic deductible identifier |
integer |
None. |
| SpecialPeriodMaxOutOfPocketUrl |
Gets or sets the link to the periodic max out of pocket resource for the rule |
string |
None. |
| SpecialPeriodMaxOutOfPocketNo |
Gets or sets the periodic max out of pocket identifier |
integer |
None. |
| SpecialMonthlyDeductibleUrl |
Gets or sets the link to the monthly deductible resource for the rule |
string |
None. |
| SpecialMonthlyDeductibleNo |
Gets or sets the monthly deductible identifier |
integer |
None. |
| SpecialMonthlyMaxOutOfPocketUrl |
Gets or sets the link to the monthly max out of pocket resource |
string |
None. |
| SpecialMonthlyMaxOutOfPocketNo |
Gets or sets the monthly max out of pocket identifier |
integer |
None. |
| PharmacyPriceMin |
Gets or sets the minimum pharmacy price in order for the rule to apply |
decimal number |
None. |
| PharmacyPriceMax |
Gets or sets the minimum pharmacy price in order for the rule to apply |
decimal number |
None. |
| PharmacyPricePreTax |
Gets or sets the option for whether the pharmacy price range is the pre-tax amount |
boolean |
None. |
| PharmacyPriceCentsMin |
Gets or sets the minimum cents portion of the pharmacy price in order for the rule to apply |
decimal number |
None. |
| PharmacyPriceCentsMax |
Gets or sets the maximum cents portion of the pharmacy price in order for the rule to apply |
decimal number |
None. |
| PharmacyPriceCentsPreTax |
Gets or sets the option for whether the cents portion of the pharmacy price range is the pre-tax amount |
boolean |
None. |
| FirstFillByRx |
Gets or sets whether the rule applies to first fills |
boolean |
None. |
| RefillExpired |
Gets or sets whether the rule applies for expired refills (based on plan's Rx Expire Days) |
boolean |
None. |
| DiagnosisCodes |
Gets or sets the DiagnosisCodes for which the rule applies |
Collection of RuleDiagnosisCodeModel |
None. |
| Members |
Gets or sets members for which the rule applies; if the list is empty it applies to all |
Collection of RuleMemberModel |
None. |
| MemberListIsExclusion |
Gets or sets a value indicating whether the member list is treated as an exclusion list. If this is true, members in the list will be excluded from the rule; if false, only members in the list will be included in the rule. If the list is empty, it applies to all pharmacies regardless of this value. |
boolean |
None. |
| MemberProfileListIsExclusion |
Gets or sets a value indicating whether the member profile list is treated as an exclusion list. If this is true, member profiles in the list will be excluded from the rule; if false, only member profiles in the list will be included in the rule. If the list is empty, it applies to all pharmacies regardless of this value. |
boolean |
None. |
| Networks |
Gets or sets networks for which the rule applies; if the list is empty it applies to all |
Collection of RuleNetworkModel |
None. |
| Headquarters |
Gets or sets headquarters for which the rule applies; if the list is empty it applies to all |
Collection of RulePharmacyHeadquarterModel |
None. |
| PharmacyHeadquarterListIsExclusion |
Gets or sets a value indicating whether the headquarter list is treated as an exclusion list. If this is true, headquarters in the list will be excluded from the rule; if false, only headquarters in the list will be included in the rule. If the list is empty, it applies to all pharmacies regardless of this value. |
boolean |
None. |
| Pharmacies |
Gets or sets pharmacies for which the rule applies; if the list is empty it applies to all |
Collection of RulePharmacyModel |
None. |
| PharmacyListIsExclusion |
Gets or sets a value indicating whether the pharmacy list is treated as an exclusion list. If this is true, pharmacies in the list will be excluded from the rule; if false, only pharmacies in the list will be included in the rule. If the list is empty, it applies to all pharmacies regardless of this value. |
boolean |
None. |
| PharmacyProfileListIsExclusion |
Gets or sets a value indicating whether the pharmacy profile list is treated as an exclusion list. If this is true, pharmacy profiles in the list will be excluded from the rule; if false, only pharmacy profiles in the list will be included in the rule. If the list is empty, it applies to all pharmacy profiles regardless of this value. |
boolean |
None. |
| Prescribers |
Gets or sets prescribers for which the rule applies; if the list is empty it applies to all |
Collection of RulePrescriberModel |
None. |
| PrescriberListIsExclusion |
Gets or sets a value indicating whether the prescriber list is treated as an exclusion list. If this is true, prescribers in the list will be excluded from the rule; if false, only prescribers in the list will be included in the rule. If the list is empty, it applies to all pharmacies regardless of this value. |
boolean |
None. |
| Facilities |
Gets or sets the Facilities for which the rule applies |
Collection of RuleFacilityBranchModel |
None. |
| ExemptFromDeductible |
Gets or sets the Exempt from Deductible indicator |
boolean |
None. |
| ExemptFromOutOfPocketLimit |
Gets or sets the Exempt from Out of Pocket Limit indicator |
boolean |
None. |
| ApplyCoinsuranceAsDeductible |
Gets or sets the Apply Coinsurance as Deductible indicator |
boolean |
None. |
| QuantityMin |
Gets or sets the minimum quantity in order for the rule to apply |
decimal number |
None. |
| QuantityMax |
Gets or sets the maximum quantity in order for the rule to apply |
decimal number |
None. |
| CompoundDrugs |
Gets whether the special drug criteria applies to compound drugs |
boolean |
None. |
| UnknownDrugs |
Gets whether the special drug criteria applies to unknown drugs |
boolean |
None. |
| UndefinedDrugs |
Gets whether the special drug criteria applies to undefined drugs |
boolean |
None. |
| CompoundLevelOfEffort |
Gets level of effort values applicable to the special drug criteria |
Collection of LevelOfEffortModel |
None. |
| GroupPlanNo |
Gets or sets the group plan id associated with the rule |
integer |
None. |
| Description |
Gets or sets the description |
string |
None. |
| Priority |
Gets or sets the priority |
integer |
None. |
| ReferenceCode |
Gets or sets the reference code |
string |
None. |
| Message |
Gets or sets the message |
string |
None. |
| ChangeNote |
Gets the latest change note or sets a change note to be saved on a patch |
string |
None. |
| EffectiveStartDate |
Gets or sets the effective start date |
date |
None. |
| EffectiveEndDate |
Gets or sets the effective end date |
date |
None. |
| Active |
Gets or sets whether the rule is active |
boolean |
None. |
| DaysSupplyMin |
Gets or sets the minimum days supply in order for the rule to apply |
integer |
None. |
| DaysSupplyMax |
Gets or sets the maximum days supply in order for the rule to apply |
integer |
None. |
| MemberAgeMin |
Gets or sets the minimum age of the member in order for the rule to apply |
integer |
None. |
| MemberAgeMax |
Gets or sets the maximum age of the member in order for the rule to apply |
integer |
None. |
| MemberAgeUnits |
Gets or sets the age units. |
string |
None. |
| DependentRelationshipCodes |
Gets or sets the dependent relationship code as a delimited list for which the rule applies. |
Collection of RelationshipModel |
None. |
| ServiceCategory |
Gets or sets the service category |
string |
None. |
| MemberGender |
Gets or sets the gender (if necessary) for which the rule applies |
string |
None. |
| PharmacyTypes |
Gets or sets the list of acceptable pharmacy types |
Collection of RulePharmacyTypeModel |
None. |
| SubmissionClarificationCodeCriteriaType |
Gets or sets the rule's submission clarification code match criteria if applicable (possible values: Blank, Match, n/a) |
string |
None. |
| SubmissionClarificationCodes |
Gets or sets the submission clarification codes for which the rule applies (This list is only used if SubmissionClarificationCodeCriteriaType is set to match) |
Collection of RuleSubmissionClarificationCodeModel |
None. |
| PharmacyServiceTypeCriteriaType |
Gets or sets the pharmacy service criteria type |
string |
None. |
| PharmacyServiceType |
Gets or sets the pharmacy service value. Uses standarded NCPDP values. |
string |
None. |
| PatientResidenceCriteriaType |
Gets or sets the patient residence criteria type |
string |
None. |
| PatientResidence |
Gets or sets the patient residence value. Uses standarded NCPDP values. |
string |
None. |
| PlaceOfServiceCriteriaType |
Gets or sets the place of service criteria type |
string |
None. |
| PlaceOfService |
Gets or sets the place of service value. Uses standarded NCPDP values. |
string |
None. |
| BenefitCodeUrl |
Gets or sets the Benefit Code Url |
string |
None. |
| BenefitCodeNo |
Gets or sets the Benefit Code number |
integer |
None. |
| PriorFillsMin |
Gets or sets the Prior Fills Minumum |
integer |
None. |
| PriorFillsMax |
Gets or sets the Prior Fills Maximum |
integer |
None. |
| PriorFillsDaysInterval |
Gets or sets the Prior Fills Interval Days |
integer |
None. |
| PriorFillsGraceDays |
Gets or sets the Prior Fills Grace Days |
integer |
None. |
| PriorFillsStartDate |
Gets or sets the Prior Fills Start Date |
date |
None. |
| PriorFillsDaysSupplyMin |
Gets or sets the Prior Fills Days Supply Minimum |
integer |
None. |
| PriorFillsDaysSupplyMax |
Gets or sets the Prior Fills Days Supply Maximum |
integer |
None. |
| PriorFillsDrugProfileUrl |
Gets or sets the Prior Fills Drug Profile Url |
string |
None. |
| PriorFillsDrugProfileNo |
Gets or sets the Prior Fill Drug Profile number |
integer |
None. |
| PriorFillsPharmacyProfileUrl |
Gets or sets the Prior Fills Pharmacy Profile Url |
string |
None. |
| PriorFillsPharmacyProfileNo |
Gets or sets the Prior Fills Pharmacy Profile number |
integer |
None. |
| PriorFillsGPIChars |
Gets or sets the Prior Fills GPI Chars |
string |
None. |
| PriorFillsLimitToCurrentPeriod |
Gets or sets the Prior Fills Limit to Current Period |
boolean |
None. |
| PriorFillsByRxNumber |
Gets or sets the Prior Fills Limit to Submitted Rx Number |
boolean |
None. |
| PriorFillsByNDC |
Gets or sets the Prior Fills Limit to Submitted NDC |
boolean |
None. |
| DiagnosisCodeCriteriaType |
Gets or sets the rule's submission clarification code match criteria if applicable (possible values: Blank, Match, n/a) |
string |
None. |
| DAWCodes |
Gets or sets the acceptable DAW code values that apply to the rule |
Collection of DAWCodeModel |
None. |
| ContractCodes |
Gets or sets the list of contract codes associated with the general criteria |
Collection of RuleContractCodeModel |
None. |
| ARCodes |
Gets or sets the list of AR codes associated with the general criteria |
Collection of RuleARCodeModel |
None. |
| CoverageLevels |
Gets or sets the coverage levels associated with the general criteria |
Collection of RuleCoverageLevelModel |
None. |
| EmployeeStatuses |
Gets or sets the list of employee statuses associated with the general criteria |
Collection of RuleEmployeeStatusModel |
None. |
| OtherStatuses |
Gets or sets the list of other statuses associated with the general criteria |
Collection of RuleOtherStatusModel |
None. |
| MemberStates |
Gets or sets the list of US States associated with the general criteria |
Collection of RuleMemberStateModel |
None. |
| PharmacyStates |
Gets or sets the list of US States associated with the general criteria |
Collection of RuleStateModel |
None. |
| isTemplate |
Gets or sets whether the rule is a template |
boolean |
None. |
| IsOverridden |
Gets or sets the flag if this rule is overridden |
boolean |
None. |
| OverridingRuleURL |
Gets or sets the rule template thats being overridden |
string |
None. |
| Enabled |
Gets or sets the rule template is enabled |
boolean |
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. |