FORMULARY 3.

0 QUICK REFERENCE GUIDE

Contents
FUNCTIONALITY CHANGES FROM FORMULARY 1.0 TO 3.0...................................2
PRESENTING FORMULARY & COVERAGE INFORMATION........................................3
FORMULARY STATUS USING REPRESENTATIVE NDC...........................................4
FORMULARY ROLL-UP........................................................................................... 5

FORMULARY 3.0 QUICK REFERENCE GUIDE

FUNCTIONALITY CHANGES FROM FORMULARY 1.0 TO 3.0

The definition of the value 03 in Product/Service ID Qualifier was changed

to National Drug Code (NDC) to match the July 2007 External Code List (ECL).
A new Product/Service ID Qualifier 36 (Representative National Drug Code
(NDC)) was added.
External Code List values were removed from the data elements with a note
to see the NCPDP External Code List. Values remained where the field was
constrained in the Surescripts Implementation Guide.
To provide a dependable base of information for Formulary and Benefit
transmissions, the Formulary Status List is now required to be sent by PBMs
(section Formulary Data Overview). Additionally, the Formulary Status List
Header provides fields that allow the sender to specify a default formulary
status for non-listed drugs. In some cases, this is all the information that is
necessary to describe the formulary. Verbiage was added to allow omission of
Formulary Status Detail records when the non-listed formulary policies are
used exclusively to convey the drugs formulary statuses in section General
Structural Overview and Formulary Status List. Minor clarifications were
made in sections High-Level Processing Examples and File Processing
Options.
The Classification List and references to it (such as Drug Classification
Information) has been removed due to lack of use. The Classification ID has
been removed from the Cross Reference Detail.
Coverage Information Detail Medical Necessity (MN) and Resource Link
Summary Level (RS) have both been removed.
Formulary Status value 2 was clarified to On Formulary/Non-Preferred. Value
3-99 was clarified to On Formulary/Preferred. If formulary status of targeted
drug is 2 or less, the technology vendor will need to check payer specified
and therapeutic alternatives. Requirement is to display those alternatives
with a formulary status higher than the targeted drug. (Reqt. 4.10 from ACR
document)
Section Coverage Information added Text message support. A payer may
send multiple quantity limits, step medications, text messages and resource
links for the same drug.
Section Copay Information added a bullet about Copay specific text
message.
Coverage Information Detail Coverage Text Message The field Message
Short (942-GP) and Message Long (941-GN) comments have been modified.
The field Text Message Type (A46-1S) has been added. This field was
added to tie a message to a specific coverage restriction or as a general
message
o The qualifier FM (formulary) was introduced to ensure consistency
between this field and the Resource Link Field.
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FORMULARY 3.0 QUICK REFERENCE GUIDE

An example of how it could be used is to denote a clients Specialty

Designated Pharmacy option. For example, This drug is part of the
Designated Specialty Pharmacy Program. Call ABC Company at 1877-555-1212.
The following fields now reference RxNorm: (NCPDP Element ID#)
o Product/Service ID (407-D7)
o Drug Reference Number (915-B6)
o Product/Service ID Source (962-HY)
o Drug Reference Number Source (919-CS)
o Product/Service ID Alternative (958-HU)
o Drug Reference Number Alternative (917-B8)
o Product/Service ID Step Drug (960-HW)
o Drug Reference Number Step Drug (921-CU)
RxNorm Code and Qualifier are no longer designated for future use.
o

PRESENTING FORMULARY & COVERAGE INFORMATION

For each medication presented to the prescriber:

1. Note the medications NDC(s) (drug ID hereafter). There could be a list
of NDCs associated with the drug that they get from their drug database.
For example, Lipitor 40mg tablet may have 15 NDCs available in their
Drug Database (i.e., Medispan) that are NOT obsolete, unit dose, private
label or repacked. (If rolled-up, see Formulary Status Using
Representative NDC below.)
2. Determine the patients Formulary ID and Coverage ID using the Eligibility
transaction.
3. Determine the medications formulary status:
a. Search the Coverage Information Detail - Product Coverage
Exclusion list for this drug ID and Coverage ID. If exclusion is found,
present Not Reimbursable as the formulary status.
b. If no Product Coverage Exclusion is associated with this medication,
search the Formulary Status List with the entire list of NDCs from
step 1 above and present the Formulary Status reflected there
based on these NDCs.
c. If the payer has not included any of these drug IDs in the Formulary
Status List, use the appropriate non-listed default status specified in
the Formulary Status Header (if provided by the payer):
- Non-Listed Prescription Brand Formulary Status
-

Non-Listed Prescription Generic Formulary Status

Non-Listed Brand Over The Counter Formulary Status

Non-Listed Generic Over The Counter Formulary Status

Non-Listed Supplies Formulary Status

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FORMULARY 3.0 QUICK REFERENCE GUIDE

FORMULARY STATUS USING REPRESENTATIVE NDC

The payer provides formulary status using 11-digit representative NDCs, rather than
supplying NDCs for all of a medications packaging variations. On its Formulary
Status List, the payer includes one NDC for each label name medication
representing that drug name/strength/dosage form combination.
In the example below, the payer has included just one NDC11 to represent Zyprexa
10 mg Tablet, though there are multiple package variations for the medication (a 60
count bottle, a 1,000 count bottle, and a unit dose pack, along with other variations
offered by repackagers). Following the guidelines set out elsewhere in this guide,
the payer included an NDC which is (a) not repackaged, (b) not obsolete, and (c) not
a unit dose pack.
Note: The payer in this example does not employ the Product Coverage
Exclusion list. See a separate example in the guide for an illustration of its
use.
Below is a conceptual process for locating a medication within a Formulary Status
List containing representative NDCs. Note that different system implementations of
this logical process are possible.
Step one: Retrieve the patients payers participant ID (P00010), and Formulary
ID (100) from the 271 transaction.
Step two: Reference a third-party or proprietary drug database to gather all
NDCs associated with the prescription-level medication being considered:
00002-4117-04 (1,000 count bottle)
00002-4117-33 (100 count blister pack)
00002-4117-60 (60 count bottle)
Step three: Search Formulary Status List 100 for each NDC gathered in the
preceding step. Once a match is made, note the Formulary Status.
In this example, the third NDC was listed by the payer: 00002-4117-60, with a
Formulary Status value of 2.
Therefore, the formulary status for the label name drug, Zyprexa 10 mg Tablet,
is 2 On-Formulary.

FORMULARY 3.0 QUICK REFERENCE GUIDE

FORMULARY ROLL-UP
Formulary Roll-Up is a process by which Surescripts will roll-up PBM formulary data
and significantly decrease the file size to make it easier for prescriber vendors to
download and integrate into their systems. This will solve a major pain point for all
participants on the network.
What is the benefit of Formulary Roll-Up?
1) It helps prescriber vendors maintain compliance with weekly downloading of
the PBM formulary files.
2) It reduces the size of the formulary that prescriber vendors need to download
on a weekly basis.
a. We expect file sizes to grow even larger as PBMs start to send ePA
data, so moving to 3.0 and utilizing roll-up is vital for prescriber
vendors to be able to access all relevant ePA information.
b. We are able to the decrease the formulary file size by the following
percentages:
i. FDB: 61.01%
ii. Medispan: 58.18%
iii. Alchemy: 72.81%
iv. VantageRx (Multum): 77.32%
v. DIT: 80.26%
vi. Redbook: 71.79%
3) It allows Surescripts to identify and work with PBMs to resolve formulary
quality issues.
4) Improves end-user experience at the point of care.
What drug databases are supported for Formulary Roll-Up?
Surescripts will support the following drug databases:
* Drug Information Technologies (DIT)
* First Databank
* Gold Standard Drug Database
* Multum
* Medispan
* Thomson Reuters Micromedex/RED Book
Will the formulary files look any different in WebDAV?
No. The WebDAV directory structure will not change and you will be able to find
smaller versions of each PBMs files when you retrieve them from WebDAV.

FORMULARY 3.0 QUICK REFERENCE GUIDE

What is WebDAV?
WebDAV is an extension of HTTP that allows for collaboration between users. Its
essentially a big folder, hosted by Surescripts, that PBMs can put their formulary
files into and that prescriber vendors retrieve formulary files from.
Will the formulary data for all PBMs be rolled up?
No. There may be certain PBMs who do not allow Surescripts to roll-up their data.
Those files will be available just as they are now and prescriber vendor systems will
have to utilize their current process for rolling up the formulary data.
My system already rolls up formulary data. How will Surescripts
Formulary Roll-Up process affect this?
Surescripts will follow the same rules in rolling up the formulary data that it
currently outlines in the Prescription Benefit Implementation Guide. During
Implementation, prescriber vendors will be provided with a drug database-specific
implementation guide outlining how Surescripts chooses a Representative NDC for
that drug database.