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Exercise 4 - Pharmacy Pricing: Caremark Confidential
Exercise 4 - Pharmacy Pricing: Caremark Confidential
In order to construct new plan setups, you must go into the ‘Pre-Production’ environment and create the new or updated elements.
Step 1. From CCT600, type on the command line ‘CMX000’ and press Enter.
1. Eligibility/Claim Transaction
2. Product
3. Manual Claim
4. Plan
5. Price
6. Drug Utilization Review (DUR)
7. Provider
8. Profile
9. Batch Process
10. Miscellaneous Tables
11. Call Queue Menu
12. Client Specific Menu
13. RxMAX System
90. Signoff
Selection or Command
===> CMX000
F1=Help F3=Exit F4=Prompt F6=Wrk Msg F9=Retrieve
F12=Return F14=WRKSBMJOB F18=WRKSPLF F22=Calculator F23=Calendar
Step 2. Type 1 and press Enter to access the Pre-Production environment with existing production eligibility.
90. Signoff
Selection or Command
===> 1
F1=Help F3=Exit F4=Prompt F6=Wrk Msg F9=Retrieve
F12=Return F14=WRKSBMJOB F18=WRKSPLF F22=Calculator F23=Calendar
Step 3 – Type a 2 next to the BAR you created during Exercise 2 and press Enter to edit.
Step 4 – From the CCT600 menu, type 5 on the command line and press Enter.
1. Eligibility/Claim Transaction
2. Product
3. Manual Claim
4. Plan
5. Price
6. Drug Utilization Review (DUR)
7. Provider
8. Profile
9. Batch Process
10. Miscellaneous Tables
11. Call Queue Menu
12. Client Specific Menu
13. RxMAX System
90. Signoff
Selection or Command
===> 5
F1=Help F3=Exit F4=Prompt F6=Wrk Msg F9=Retrieve
F12=Return F14=WRKSBMJOB F18=WRKSPLF F22=Calculator F23=Calendar
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Step 5 – From the Price Maintenance menu, type 1 and press Enter.
Selection or Command
===> 1
F1=Help F3=Exit F4=Prompt F6=Wrk Msg F9=Retrieve
F12=Return F14=WRKSBMJOB F18=WRKSPLF F22=Calculator F23=Calendar
Step 6 – Type 1 and press Enter to create Pharmacy pricing ( This Pricing schedule is used to set
the price of the drug as specified by the Pharmacy .It is implemented while adding the Price
Schedule Override in setting up the Plan for specific pricing options).
1. Pharmacy Price
2. Client Price
3. Patient Pay
4. Benefit Pricing Profile
5. Original Pricing
6. Cross Reference Base
7. Claim Pricing Priority Table
Selection or Command
===> 1
F1=Help F3=Exit F4=Prompt F6=Wrk Msg F9=Retrieve
F12=Return F14=WRKSBMJOB F18=WRKSPLF F22=Calculator F23=Calendar
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Step 7 – This screen contains a list of all the existing Pharmacy Price schedules in alpha-numeric
order.
? Schedule Description
(219ELPR 219ELPR
$$KKSKS
$$MMTEST
$TESTMM
***TEST*** ** TEST
**TEST** *TEST
**TEST*** *TEST
*AJP001 *AMY'S TEST
*AWTEST *AWTEST PRICE
*CRSRX +
Step 8 – For the price schedule definition you can give any name, here type in your initials +
“RTL1”.
Price Schedule
Client Code
F3=Exit F4=Prompt
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Step 9 – Client code can be used to limit the price schedule to a specific carrier. This is
particularly needed when in order that only those members under that specific Carrier will be able
to use this Price Schedule. Place your cursor on the Client Code field and press F4. Your screen
will display a list of available client codes. Type TRAIN at the top of the screen and press Enter
to scroll to that selection. Type 1 next to Carrier TRAIN and press Enter.
Step 10 – You are returned to the Add screen with a prompt to confirm that you want to create the
schedule. Type ‘Y’ and you will automatically go to the next screen.
F3=Exit F4=Prompt
CONFIRM: N (Y/N)
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Step 11 – Type in a description to match the example below. This description contains abbreviations
that would be common in naming a production price schedule.
All/Formulary All/Formulary
Compound 2. Y 10. Y 22. N 30. N
Formulary Formulary
Generic (Y) 4. Y 11. N 24. N 31. N
Brand
Original (O) 5. Y 12. N 25. N 32. N
Single-Source (N) 6. Y 13. N 26. N 33. N
Multi-Source (M) 7. Y 14. N 27. N 34. N
Sales Tax C Yes; Allow Sbm % and Flat
Allow $0.00 Sbm Cost N
Step 12 – Fill in the pricing table to match the illustration below. Any drug that is not formulary
and not a compound will price with this table. Press Enter and then respond Y to confirm.
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CONFIRM: Y (Y/N)
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Step 13 – You are automatically returned to the pharmacy price schedule screen. Change the
indicator to ‘Y’ for Formulary Compound (2), Generic (4), and Brand-Original (5) tables. Change the
indicator to ‘C’ for the Sales Tax field. The price schedule here is setup for products that are
compound, generic, original. Price for any other product will be picked up from standard price
schedule defined in option 1. Price Schedules can be setup for paid and captured claims based on the
products in the formulary list or not. Press Enter.
Step 14 – Type 5 in the Table number field at the top of the price schedule and press Enter.
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Step 15 - You are creating the price table for formulary “O” drugs. “O” is the generic indicator.
It means that the drug is the original “brand-name” drug, but that generics are available.
Step 16 - You will be prompted for the name of the MAC List. Put your cursor on the MAC List 2
field and press F4. MAC is the maximum allowable cost. MAC list is the list of all products for
which the price schedule check for the price. In this case, the price for that product should not go
above 100%.
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Added Changed User
+
F3=Exit F12=Previous
MAC List must be entered.
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Step 17 – Type ‘1’ next to the entry for *DEFAULT - MAC01 and press Enter
F3=Exit F12=Previous
Step 18 – You are returned to the Price Detail screen where the MAC list field for Cost Code 2 now
contains MAC01. Press Enter and confirm with Y at the prompt
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Step 19 – Type 4 and press Enter. This table is for formulary “Y” drugs. “Y” is the multi-source
indicator. It means that the drug is a generic drug.
Fill in the pricing table to match the illustration below. Press Enter. Type MAC01 in field for MAC
List 2 and press Enter. Confirm with Y at the prompt.
Step 20 – Type 2 and press Enter. This table is used to price compounds.
Fill in the pricing table to match the illustration below. Compounds will be set up in the plan to
be priced using the most expensive ingredient. Note that the drug cost is calculated at 300% of AWP.
This is done to compensate the pharmacy for additional ingredients and labor in preparing the
compound.
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Fee 3 Step# Minimum Cost + Fee
Step 21 – Press F12 to return to the Price Schedule list. Copy the price schedule you just created.
Type 3 next to the price schedule on the list and press Enter.
? Schedule Description
3 CBRTL1 RTL86%AWP+1.50/MAC01+1.50
CDHP_PR FOR CDHP QA TESTING
CLACWH0630
CLADD%NEG
CLCCPR002 CAL CD PR 002
CLPS0628 TEST
CLPS0630AA TEST 0630AA
CLTAMT0630
CLTEST0001 TEST
CLTOTAMT 1EST TOTAL AMOUNT
CLTOTAMT00 TEST +
Step 22 – Type in a price schedule definition, changing the last digit to ‘2’. Type in a similar
description with 1.50 replaced by 2.00 which will be the dispensing fee for the new schedule. Type
TRAIN for the Client Code. Press Enter and confirm with Y.
Description
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F3=Exit F12=Previous
CONFIRM: Y (Y/N)
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Step 23 – Type a 2 next to the new price schedule and press Enter.
? Schedule Description
CBRTL1 RTL86%AWP+1.50/MAC01+1.50
2 CBRTL2 RTL86%AWP+2.00/MAC01+2.00
CDHP_PR FOR CDHP QA TESTING
CLACWH0630
CLADD%NEG
CLCCPR002 CAL CD PR 002
CLPS0628 TEST
CLPS0630AA TEST 0630AA
CLTAMT0630
CLTEST0001 TEST
CLTOTAMT 1EST TOTAL AMOUNT +
Step 24 – Type 1 and press Enter to change the Standard pricing table.
All/Formulary All/Formulary
Compound 2. Y 22. N
Formulary Formulary
Generic (Y) 4. Y 24. N
Brand
Original (O) 5. Y 25. N
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Step 25 – Update the standard pricing table, making the fee $2.00.
Press Enter to update and confirm with a Y. Press F12 to return to the previous screen.
Step 26 – Change the fee to $2.00 for the Formulary O, Formulary Y and Compound tables. Then, press
F12 to return to the Price Schedule list screen.
Step 27 - Copy the price schedule you just created. Type 3 next to the price schedule on the list
and press Enter.
? Schedule Description
3 CBRTL2 RTL86%AWP+2.00/MAC01+2.00
CDHP_PR FOR CDHP QA TESTING
CLACWH0630
CLADD%NEG
CLCCPR002 CAL CD PR 002
CLPS0628 TEST
CLPS0630AA TEST 0630AA
CLTAMT0630
CLTEST0001 TEST
CLTOTAMT 1EST TOTAL AMOUNT
CLTOTAMT00 TEST +
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F3=Exit F6=Add F12=Previous
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Step 28 – Type in a price schedule definition= your initials + “MAIL”. Type in a description
identifying this as a Mail Pharmacy price schedule. Type TRAIN for the Client Code. Press Enter
and confirm with Y.
Description
F3=Exit F12=Previous
CONFIRM: Y (Y/N)
Step 29 - Type an 2 next to the new price schedule and press Enter.
? Schedule Description
2 CBMAIL CB MAIL PHARMACY NET
CBRTL1 RTL86%AWP+1.50/MAC01+1.50
CBRTL2 RTL86%AWP+2.00/MAC01+2.00
CDHP_PR FOR CDHP QA TESTING
CLACWH0630
CLADD%NEG
CLCCPR002 CAL CD PR 002
CLPS0628 TEST
CLPS0630AA TEST 0630AA
CLTAMT0630
CLTEST0001 TEST +
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Step 30 – Type 1 and press Enter to edit the standard pricing table.
Step 31 - Update the standard pricing table to change Cost Code 1 to 84%. 84% means that the
pharmacy will charge 84% of the AWP of the product.
Press Enter to update and type Y to confirm. Press F12 to return to the previous screen.
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Added 7/05/05 Changed 7/05/05 User CBONNER
+
F3=Exit F11=Delete F12=Previous
CONFIRM: Y (Y/N)
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Step 32 - Change the Cost Code 1 percentage to 84% for both the Formulary O and Formulary Y tables.
Step 33 - The CBMAIL price schedule does not have a Compound price table. Set the flag for compound
to ‘N’.
Step 34 – Press F3 5 times to return to th BAR selection screen. Your BAR should still display ACT status. F3 2 more times to exit Plan Database.
Always be sure to totally exit from Plan Database so that your changes are correctly stored for the BAR.
Exercise 4 is complete.
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