DatA Request Form - East

The following information is necessary to conduct a thorough pharmacy benefit analysis.
Additionally, line item prescription specific data is the most effective way to evaluate the
effects of new pricing or trend management programs. Please see the detailed list below of
data elements necessary to provide a definitive analysis. Please contact Andy Reeves with
any questions at 269-217-1672 or a.reeves@ascendpbm.com.

COMPANY INFORMATION

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CURRENT PLAN INFORMATION

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Formulary/Rebate Program

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INFORMATION REQUESTED – CURRENT PLAN

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Please provide summary pharmacy utilization data for the last 12 months, including:

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PROGRAM FEES

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LINE ITEM PRESCRIPTION SPECIFIC DATA

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To provide the most accurate analysis possible, we require a minimum of the most recent three months’ prescription data (and prefer a twelve-month time period if possible). The data should be line item, inclusive of each individual prescription and should include each of the following data points at a minimum:

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- Unique member identifier (necessary only if formulary disruption or clinical program modeling requested)

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- Member eligibility indicator (Active, Medicare-eligible, etc.)

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- Processing or Fill Date

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- Prescription Number

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- Pharmacy NCPDP Number

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- Pharmacy Name

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- Pharmacy City

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- Pharmacy State

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- NDC 11

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- Drug Name

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- Drug Type – SSB, MSB or Generic

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- Compound Indicator

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- Quantity

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- Days Supply

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- AWP based on Post AWP Price Change rates

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- Ingredient Cost

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- Dispensing Fee

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- Tax

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- Gross Cost

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- Administration Fee (if any)

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- Member Payment (includes Copay, deductible and out-of-pocket amounts)

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- Plan Cost

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- U&C

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- Formulary Status Indicator

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- Source (Mail, Retail, Specialty, and Direct Member Reimbursement Indicator)

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- Maintenance Indicator

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- Specialty Drug Indicator

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- Claim Status Type (P=Paid, C=Canceled, R=Reversal)

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Drag files here or choose files

 

Please contact Andy Reeves with any questions at:
269-217-1672 or a.reeves@ascendpbm.com

ARE YOU READY TO DISCUSS YOUR BENEFIT PLAN WITH AN EXPERT?