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Entering Health Plan and Formulary Information

Managed-care account managers can use the Account Plan Formulary view to enter and maintain information about health plan designs and formularies owned or administered by the account and about the products on those formularies. Account managers associate P & T committee members and track formulary review dates to be well prepared for calling on their contacts in the account.

Sales representatives, making professional calls might hear about contacts' roles in P & T committees. They also can review the Plan Formulary information and add their contacts to the P & T member list as appropriate.

This task is a step in Scenario for Managed Care.

Who Owns the Formulary?

There are two approaches to setting up formularies in Siebel Life Sciences. The formulary can belong to one of the following:

• The MCO account
• The PBM account

Before deciding which type of account should own the formulary, review Indicating Affiliations Between a Contact and an Account and Entering Formulary Information for Managed Care Business Plans, and consider your own business process.

Creating Health Plan Information For an Account

This task explains how to create health plan information for an account.

To create health plan information for an account

1. Navigate to the Accounts screen, then the Accounts List view.
2. In the Accounts list, drill down on an account.
3. Click the Plan Formulary tab.
4. In the Plan Design list, create a new record and complete the necessary fields.

   Some fields are described in the following table.

   Field	Comment
   Plan Type	See Table 19 for definitions of the default values in this LOV.
   No. of Lives	Number of lives in the health plan. This number cannot exceed the total lives entered for the account. NOTE:  The Total Lives field must be completed in the Account form before you enter a value in this field. (Click on the show more button to see this field.)
   % of Total Lives	Equal to [(Number of Lives at Plan Level) divided by (Number of Lives at Account Level)] multiplied by 100.
   Utilization	Number of health plan members who are using health plan benefits. This number cannot exceed the number of lives in the health plan.
   Utilization %	Equal to [(Utilization) divided by (Number of lives at Plan Level)] multiplied by 100.
   Co-Payment	Typically, the co-payment amount for a member visit to a primary care physician. The pharmacy co-payment is entered separately for each product.
   P & T Members Name	Names of contacts who are on the Pharmacy & Therapeutics committee.
   Pharmacy Distribution	Type of distribution, such as in-house, contracted, or mail-order.

Creating Formulary Information For an Account

This task explains how to create formulary information for an account.

To create formulary information for an account

1. Navigate to the Plan Formulary view.

   For information on how to navigate to the Plan Formulary view, see To create health plan information for an account.

2. In the Plan Design list, select a health plan.
3. In the Formularies list, create a new record and complete the necessary fields.

   Some fields are described in the following table.

   Field	Comment
   Type	See Table 19 for definitions of the default values in this LOV.
   Market	The option selected in this field determines which products are available in the formulary's Products list.

4. In the Products list, create a new record and complete the necessary fields.

   Some fields are described in the following table.

   Field	Comment
   Status	Off Formulary — Banned from the formulary. On Formulary — Approved by the formulary. On/Prior Auth — Physicians require MCO or PBM approval before prescribing. On/Restricted — One of the few drugs allowed its therapeutic class. On/Exclusive — The only drug allowed in its therapeutic class.
   Tier	If the product is in a tiered formulary, indicate the tier.
   Qty Limit	The quantity allowed for a patient each year.
   Competitor	This field is filled in automatically when the product's type is Competitive Product.

   By adding a product to the Products list you indicate it is on formulary and can track its status.

   NOTE:  You cannot edit the Competitor field. A check mark appears in this field if the product you selected for the Name field is a competitor's product. For more information, see Specifying a Competitor.

5. Repeat Step 3 and Step 4 until you have created a record for every product on the formulary.