EPP

View Product Coding Matrix

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Tasks:

Validate Codes Association

Provide Plan Details

Review & Validate Prod. Coding Matrix / GCPS Matrix

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Confirm/Override Plan Details

Plan Information

Plan Description:

Product Type:

Retired Date:

Closed Date:

Plan Information

Plan Description:

Product Type:

Retired Date:

Closed Date:

Deductible Embedded:

Indicator: Yes No

In Coinsurance

Percent:

Amount:

In Emergency Room Copay

Percent:

Amount:

Description:

In Family OPX

Percent:

Amount:

In Family Stoploss Coinsurance

Percent:

Amount:

In Individual OPX

Percent:

Amount:

In Individual Stoploss Coinsurance

Percent:

Amount:

In Inpatient Hospital Copay

Percent:

Amount:

Description:

In Office PCP

Percent:

Amount:

Description:

In Office Specialist Copay

Percent:

Description:

Deductible Aggregate:

In Office Visit Copay

Percent:

Amount:

Description:

In Wellness Visit Copay

Percent:

Amount:

Description:

In 2nd Tier Individual OPX

Percent:

Amount:

In 2nd Tier Coinsurance

Percent:

Amount:

In 2nd Tier Emergency Room Copay

Percent:

Amount:

Description:

In 2nd Tier Family OPX

Percent:

Amount:

In 2nd Tier Family Stoploss Coinsurance

Percent:

Amount:

In 2nd Tier Individual Stoploss Coinsurance

Percent:

Amount:

In 2nd Tier Inpatient Hospital Copay

Percent:

Amount:

Description:

In 2nd Tier Office PCP

Percent:

Amount:

Description:

In 2nd Tier Office Specialist Copay

Percent:

Amount:

Description:

In 2nd Tier Office Visit Copay

Percent:

Amount:

Description:

In 2nd Tier Wellness Visit Copay

Percent:

Amount:

Description:

In 3rd Tier Coinsurance

Percent:

Amount:

In 3rd Tier Emergency Room Copay

Percent:

Amount:

Description:

In 3rd Tier Family OPX

Percent:

Amount:

In 3rd Tier Family Stoploss Coinsurance

Percent:

Amount:

In 3rd Tier Individual OPX

Percent:

Amount:

Description:

In 3rd Tier Individual Stoploss Coinsurance

Percent:

Amount:

In 3rd Tier Inpatient Hospital Copay

Percent:

Amount:

Description:

In 3rd Tier Office PCP

Percent:

Amount:

Description:

In 3rd Tier Office Specialist Copay

Percent:

Amount:

Description:

In 3rd Tier Office Visit Copay

Percent:

Amount:

Description:

In 3rd Tier Wellness Visit Copay

Percent:

Amount:

Description:

In/Out Combined Family Deductible

Percent:

Amount:

Description:

In/Out Combined Individual Deductible

Percent:

Description:

Amount:

Out 4th Tier Coinsurance

Percent:

Amount:

Out 4th Tier Emergency Room Copay

Percent:

Amount:

Description:

Out 4th Tier Family OPX

Percent:

Amount:

Out 4th Tier Family Stoploss Coinsurance

Percent:

Amount:

Out 4th Tier Individual OPX

Percent:

Amount:

Out 4th Individual Stoploss Coinsurance

Percent:

Amount:

Out 4th Tier Inpatient Hospital Copay

Percent:

Amount:

Description:

Out 4th Tier Office Specialist Copay

Percent:

Amount:

Description:

Out 4th Tier Office Visit Copay

Percent:

Amount:

Description:

Out 4th Tier Wellness Visit Copay

Percent:

Amount:

Description:

Outpatient Surgical Facility Copay

Percent:

Amount:

Description:

Rehabilitation Therapy (SP/PT/OT)

Percent:

Amount:

Description:

Upfront Deductible

Percent:

Amount:

Description:

Upfront Family Deductible

Percent:

Description:

Amount:

Deductible Embedded:

Indicator: Yes No

In Coinsurance

Percent:

Amount:

In Emergency Room Copay

Percent:

Amount:

Description:

In Family OPX

Percent:

Amount:

In Family Stoploss Coinsurance

Percent:

Amount:

In Individual OPX

Percent:

Amount:

In Individual Stoploss Coinsurance

Percent:

Amount:

In Inpatient Hospital Copay

Percent:

Amount:

Description:

In Office PCP

Percent:

Amount:

Description:

In Office Specialist Copay

Percent:

Description:

Deductible Aggregate:

In Office Visit Copay

Percent:

Amount:

Description:

In Wellness Visit Copay

Percent:

Amount:

Description:

In 2nd Tier Individual OPX

Percent:

Amount:

In 2nd Tier Coinsurance

Percent:

Amount:

In 2nd Tier Emergency Room Copay

Percent:

Amount:

Description:

In 2nd Tier Family OPX

Percent:

Amount:

In 2nd Tier Family Stoploss Coinsurance

Percent:

Amount:

In 2nd Tier Individual Stoploss Coinsurance

Percent:

Amount:

In 2nd Tier Inpatient Hospital Copay

Percent:

Amount:

Description:

In 2nd Tier Office PCP

Percent:

Amount:

Description:

In 2nd Tier Office Specialist Copay

Percent:

Amount:

Description:

In 2nd Tier Office Visit Copay

Percent:

Amount:

Description:

In 2nd Tier Wellness Visit Copay

Percent:

Amount:

Description:

In 3rd Tier Coinsurance

Percent:

Amount:

In 3rd Tier Emergency Room Copay

Percent:

Amount:

Description:

In 3rd Tier Family OPX

Percent:

Amount:

In 3rd Tier Family Stoploss Coinsurance

Percent:

Amount:

In 3rd Tier Individual OPX

Percent:

Amount:

Description:

In 3rd Tier Individual Stoploss Coinsurance

Percent:

Amount:

In 3rd Tier Inpatient Hospital Copay

Percent:

Amount:

Description:

In 3rd Tier Office PCP

Percent:

Amount:

Description:

In 3rd Tier Office Specialist Copay

Percent:

Amount:

Description:

In 3rd Tier Office Visit Copay

Percent:

Amount:

Description:

In 3rd Tier Wellness Visit Copay

Percent:

Amount:

Description:

In/Out Combined Family Deductible

Percent:

Amount:

Description:

In/Out Combined Individual Deductible

Percent:

Description:

Amount:

Out 4th Tier Coinsurance

Percent:

Amount:

Out 4th Tier Emergency Room Copay

Percent:

Amount:

Description:

Out 4th Tier Family OPX

Percent:

Amount:

Out 4th Tier Family Stoploss Coinsurance

Percent:

Amount:

Out 4th Tier Individual OPX

Percent:

Amount:

Out 4th Individual Stoploss Coinsurance

Percent:

Amount:

Out 4th Tier Inpatient Hospital Copay

Percent:

Amount:

Description:

Out 4th Tier Office Specialist Copay

Percent:

Amount:

Description:

Out 4th Tier Office Visit Copay

Percent:

Amount:

Description:

Out 4th Tier Wellness Visit Copay

Percent:

Amount:

Description:

Outpatient Surgical Facility Copay

Percent:

Amount:

Description:

Rehabilitation Therapy (SP/PT/OT)

Percent:

Amount:

Description:

Upfront Deductible

Percent:

Amount:

Description:

Upfront Family Deductible

Percent:

Description:

Amount:

Corporate Information

Product Name:

Product Number:

Benefit Agreement: Yes No

Corporate Information

Product Name:

Product Number:

Benefit Agreement: Yes No

{NRSG}Department

Type Code:

Number:

{NRSG}Scope Of Benefit

Code:

{SG}Department

Type Code:

Number:

{SG}Scope Of Benefit

Code:

{NRSG}Department

Type Code:

Number:

{NRSG}Scope Of Benefit

Code:

{SG}Department

Type Code:

Number:

{SG}Scope Of Benefit

Code:

Drug Claim Submission Code

Value:

Retail Nonformulary

Percentage After Deductible:

Amount:

Percent:

Mail Order Generic

Percentage After Deductible:

Amount:

Percent:

Mail Order Nonformulary

Percentage After Deductible:

Amount:

Percent:

Retail Generic

Percentage After Deductible:

Amount:

Percent:

BlueScript Drugs

Percentage After Deductible:

Amount:

Percent:

Drug Tier Structure Code

Value:

Drug Rider Code

Value:

Mail Order Formulary

Percentage After Deductible:

Amount:

Percent:

Retail Formulary

Percentage After Deductible:

Amount:

Percent:

Drug Copay Type Code

Value:

Drug ID Card Mailing Code

Value:

Drug Report Format Code

Value:

Drug Program Code

Value:

Drug Mail Order House Code

Value:

Drug Card Stock Code

Value:

4th Tier Drug

Percentage After Deductible:

Amount:

Percent:

RX Percentage After Deductible

Percentage After Deductible:

Amount:

Percent:

Drug Benefit Scope Code

Value:

Drug Claim Submission Code

Value:

Retail Nonformulary

Percentage After Deductible:

Amount:

Percent:

Mail Order Generic

Percentage After Deductible:

Amount:

Percent:

Mail Order Nonformulary

Percentage After Deductible:

Amount:

Percent:

Retail Generic

Percentage After Deductible:

Amount:

Percent:

BlueScript Drugs

Percentage After Deductible:

Amount:

Percent:

Drug Tier Structure Code

Value:

Drug Rider Code

Value:

Mail Order Formulary

Percentage After Deductible:

Amount:

Percent:

Retail Formulary

Percentage After Deductible:

Amount:

Percent:

Drug Copay Type Code

Value:

Drug ID Card Mailing Code

Value:

Drug Report Format Code

Value:

Drug Program Code

Value:

Drug Mail Order House Code

Value:

Drug Card Stock Code

Value:

4th Tier Drug

Percentage After Deductible:

Amount:

Percent:

RX Percentage After Deductible

Percentage After Deductible:

Amount:

Percent:

Drug Benefit Scope Code

Value:

BlueShield Under 65 Contract Code

Code:

Special Program

Indicator:

Funding Type

Code:

BlueCross Over 65 Contract Code

Code:

BlueCross Under 65 Contract Code

Code:

Drug Contract Code

Code:

BlueShield Over 65 Contract Code

Code:

Policy Type

Code:

ID Card

Type Code:

Alpha Prefix

Code:

Type Of Business

Description:

Code:

BlueShield Under 65 Contract Code

Code:

Special Program

Indicator:

Funding Type

Code:

BlueCross Over 65 Contract Code

Code:

BlueCross Under 65 Contract Code

Code:

Drug Contract Code

Code:

BlueShield Over 65 Contract Code

Code:

Policy Type

Code:

ID Card

Type Code:

Alpha Prefix

Code:

Type Of Business

Description:

Code: