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Rx Benefit Assessment and Contract Review Questionnaire

Because accurate assessment of financial aspects are crucial to the success of any health benefit Synchrony Rx needs a minimum of the most recent six months’ prescription drug data (and prefers a twelve month time period if available). After completing the form below, the Synchrony Rx Team will contact you with instructions for secure data submission. The data should be line item, inclusive of each individual prescription and should include each of the below listed data points at a minimum.

* Please submit PAID CLAIMS ONLY (no reversals or cancelled claims). As we likely have no Business Associate Agreement or Confidentiality Agreement in place with your organization, we respectfully request that the data contain no Personal Health Information (PHI) as defined by HIPAA. Please know that all data and information will be held in the strictest confidence.

CONTACT INFORMATION

First Name

A value is required.

Last Name

A value is required.

Organization

A value is required.

Email Address

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Telephone Number

A value is required.



GENERAL

Planned Effective Date

A value is required.Invalid format.

Number of Employees on Medical Benefit

A value is required.Invalid format.The entered value is less than the minimum required.The entered value is greater than the maximum allowed.

Total Members on Medical Benefit

A value is required.Invalid format.The entered value is less than the minimum required.The entered value is greater than the maximum allowed.

Start Date of Reporting/Data Period

A value is required.Invalid format.

End Date of Reporting/Data Period

A value is required.Invalid format.


Rx PLAN INFORMATION

Gross Annual Drug Spend

A value is required.Invalid format.The entered value is less than the minimum required.The entered value is greater than the maximum allowed.

Plan Cost

A value is required.Invalid format.

Member Cost Share

A value is required.Invalid format.


Rx PLAN COST BREAKDOWN

  Plan Cost Member Cost Claim Count
Mail Brand A value is required. A value is required. A value is required.
Mail Generic A value is required. A value is required. A value is required.
Retail Brand A value is required. A value is required. A value is required.
Retail Generic A value is required. A value is required. A value is required.
Specialty Brand A value is required. A value is required. A value is required.
Specialty Generic A value is required. A value is required. A value is required.

 



REBATES

How are rebates paid?





Please make a selection.

A value is required.

A value is required.

Rebate Payments

Invalid format. OR

Invalid format.

Invalid format.

Invalid format.

 

COMMISSIONS

How would you like your compensation structured?






Please make a selection.
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NECESSARY CLAIM DATA ELEMENTS

Processing or Fill Date
Prescription Number
Pharmacy NCPDP Number
NDC 11
Drug Name
Drug Type – SSB, MSB or Generic Compound Indicator
Quantity
Days Supply
AWP based on Post AWP Price Change rates
Ingredient Cost
Dispensing Fee
Tax
Gross Cost
Administration Fee (if any)
Member Payment (includes Copay, deductible and out-of-pocket amounts)
Plan Cost
U&C
Formulary Status Indicator
Source (Mail, Retail, Specialty, and Direct Member Reimbursement Indicator)
Specialty Drug Indicator
Claim Status Type (P=Paid, C=Canceled, R=Reversal)

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