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You can create copay formulas to determine the amount of copay that should be charged in specific situations. These copay formulas can then be used in the Formulary System for an insurance provider.


Insurance Formulary Systems may be useful if you are self-insuring. These systems allow you to set up copay amounts and coverage details for a third party. If you are handling insurance claims in-house, you will want to set up a third party that uses your specific Formulary and Copay settings.




Creating a New Copay Formula

Creating Additional Formula Tiers



Creating a New Copay Formula

To set up a new formula, follow these instructions:


1.Click on the System menu item and select the Copay option.

2.Click on the Create New Copay Formula option.

3.Enter a Name for this formula.

4.The Break Type field relates to the "Up To" amount you will enter in your copay formula tiers. In this field, you can choose to break by Quantity, Price, or Day Supply.


A different formula tier can be used for sales up to a certain price (or quantity, or day supply). For example, for sales up to $50 you may want to use a formula tier that charges 15% of the cost, and then create a tier that charges 10% for sales between $51 and $100.


5.When you have chosen a Break Type, click Save.

6.Click on the Formula Tiers tab.

7.In the "Formula Tiers" section, click on the Add New option.

8.In the Up To field, enter the highest price (or quantity, or day supply, depending on your Break Type) that will use this formula tier. Any sales for a larger amount will need to use a different tier.


If you only want to use one formula tier, you can create a very large Up To amount (e.g., "999999") to ensure that all sales will use the same formula.


9.In the Percent field, choose the correct percentage to charge. Then, in the Percent Of field, click on the drop-down arrow to select either Cost or Price. (There is also a Returned Copay option to handle instances where an insurance provider has returned a copay.) In this way, you can choose settings such as "10 Percent of Cost," "15 Percent of Price," etc.

10.The Modify Amount is a flat dollar amount that will be added to the charge (or subtracted from it).


After the copay amount is calculated (based on the percentage you have entered), the number entered in the Modify Amount field will be factored into the copay. If you enter "5" into this field, five dollars will be added to the copay amount. If you enter "-5" then five dollars will be subtracted from the copay.


11.In the Minimum Copay and Maximum Copay fields, enter the minimum and maximum amounts that customers will be charged when you are using this formula tier.

12.When you are ready, click Save.



Creating Additional Formula Tiers

You can create as many formula tiers as needed. For example, you may want one tier for sales up to a quantity of 30, and a different tier for quantities of 31-60. After you have created the first formula tier, click on the Save button and then, under the Formula Tiers tab, click Add New to enter the next tier's information.


If you only want to use one formula tier, you can create a very large Up To amount (e.g., "999999") to ensure that all sales will use the same formula.



See Also

Insurance Formulary System