Insurance Formulary System

<< Click to Display Table of Contents >>

Navigation:  System >

Insurance Formulary System

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.

 

The Copay formulas that you have created can be used within a Formulary System. This system can be tied to a specific insurance provider. The formulary will determine which copay systems will be used for which drugs (or types of drugs). It will also determine whether those drugs are covered by the insurance.

 

Topics

Creating a New Formulary System

How Do I Tie the Formulary to an Insurance?

Explanation of GPI Numbers

 

 

Creating a New Formulary System

To set up a new system, follow these instructions:

 

1.Click on the System menu item and select the Insurance Formulary System option.

2.Click on the Create New Insurance Formulary System option.

3.Enter a Name for this formulary system.

4.Click Save.

5.Click on the Formularies tab.

6.Click on the Add New option.

7.In the Coverage Type field, click on the drop-down arrow and choose either "Covered" or "Not Covered." This will determine whether the selected drug (or drug type) will be covered by the insurance.

8.In the Drug Identifier field, you can type "brand" or "generic" to use this formulary for either brand or generic drugs. Another option is to type a specific NDC number. You can also enter a partial or complete GPI number to include drugs within a certain class. (For more information on using partial GPI numbers, see the "Explanation of GPI Numbers" section below.)

9.In the Copay Formula field, begin typing to start a search for the correct copay. This copay formula will be used with your chosen drug (or drug type).

 

 

How Do I Tie the Formulary to an Insurance?

Insurances can be tied to a formulary system within the Insurance maintenance screen. When editing details for an insurance provider, locate the Insurance Formulary System field. In this field, you can run a search for the formulary systems that you have created. Once you have selected the correct system and saved your changes, it will be tied to that insurance provider.

 

Each insurance provider can only be tied to one formulary system.

 

 

Explanation of GPI Numbers

A full GPI number has 14 digits and applies to a specific drug with a specific dosage form and strength. However, you can also use a partial GPI number to encompass a group of drugs that fall within a basic category. In the Drug Identifier field discussed above, you can choose to enter a partial GPI number so that your formulary system applies to a group of drugs. For more information on how GPI numbers are broken down, see the table below.

 

GPI

Coding

Example

58-

Drug Group

Antidepressants

58-20-

Drug Class

Tricyclic agents

58-20-00

Drug sub-class

Tricyclic agents

58-20-00-60

Drug name

Nortriptyline

58-20-00-60-10

Drug name extension

Nortriptyline HCL

58-20-00-60-10-01

Dosage form

Nortriptyline HCL Capsule

58-20-00-60-10-01-05

Strength

Nortriptyline HCL Capsule 10mg

 

See Also

Copay

Insurances

Reason Codes