Form 62 Pharmacies Event Form

MEDICAL EXPENDITURE PANEL SURVEY

MEDICAL PROVIDER COMPONENT

DATA FORM

FOR

PHARMACIES

for

REFERENCE YEAR 2022

Specifications for RCD

PROGRAMMERS: This document details the specifications for the Pharmacy Data Form.

Overall functionality requirements we would like for the system controlling the data forms are as follows:

• Show an “overall” progress indicator on the screen.

• Set up FUNCTION KEYS for each of the following commands:

1. Don’t Know

2. Refused

The function keys would be available for any question unless specified otherwise in the question by question specifications.

NOTE: 2018 Update: The response option of “Retrievable” was removed from all Event Forms.

• To assist the DCS/abstractors if they need to jump around a form, among forms, and among patients for a given provider:

  • Within a data form, in addition to post-logic, include pre-logic to the area we are skipping to, so the interviewer wouldn’t be able to access a group of questions without answering the gateway question.

• Incorporate edit trails (e.g., if need to go back and revise answer).

• Include in the screen header some sort of progress status on how many patients for a given pharmacy have been completed out of the total (e.g., Done with 2 of 3 patients).

• Allow the DCS/abstractors to see a list of the data forms completed for a given patient (with fill dates) in case they need to go back to revise some information in one of the forms.

• Once the DCS/abstractors finish with one patient they are taken back to a summary screen listing all patients for that provider, so they can click on the next patient.

Question By Question Specifications

The QxQ specifications have been broken out throughout the rest of this document by section and include the screen layout, programmer notes, and edit specifications from Westat.

NOTE:

The variable names have been included where radio buttons or text boxes should appear. The variables in RED FONT were new for base year (2009). The variables in GREEN FONT were new for Option Year 1 (2010). The variables in PURPLE FONT are new for Option Year 2 (2011). The variables in BLUE FONT are those that were used by WESTAT.

NOTE:

Westat EDIT SPECS: Westat editors wrote BLUE SHEETS to the TRC (telephone research center) for data items that needed collection, clarification, or correction. The TRC is our contact with the respondent in the provider’s office.

Westat editors wrote YELLOW SHEETS for problematic items that needed managerial review.

OMB

READ THIS ALOUD ONLY IF REQUESTED BY RESPONDENT.

 

OMB Statement

 

Public reporting burden for this collection of information is estimated to average 3 minutes per response, the estimated time required to complete the survey. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-0118) AHRQ, 5600 Fishers Lane, Rockville, MD 20857.

OMB No. [#]; Exp. Date [DATE]

1. CONTINUE

SCREEN LAYOUT

Q1. Enter Date Filled ENC_DATE

DCS: ENTER A DATE IN FORMAT MM/DD/YYYY. INCLUDE LEADING 0’s FOR SINGLE DIGIT MONTHS AND DAYS.

Q2. Prescription information will be identified using: 1 = NDC

2 = Drug Name, Strength/Unit, and Dosage Form

DCS: TRY TO OBTAIN NDC. USE DRUG NAME

ONLY IF NDC NOT AVAILABLE.

R_RXIDTYPE

Q2a. NDC NDC

ENTER 11-DIGIT NDC WITHOUT DASHES OR SPACES.

NDC IS UNKNOWN OR REFUSED, RETURN TO PREVIOUS SCREEN AND SELECT DRUG NAME OPTION

PROGRAMMER NOTES

2018 UPDATE: Add Blaise trigram lookup for NDC.

2017 UPDATE: Staff need to be able to see the drug name associated with the NDC they’ve entered. When the NDC code is entered in the NDC field, display the additional drug name info in the NDC_NAME and NDC_NAME2 fields on the screen.

2017 UPDATE: Alert pop up box indicating that the same NDC and/or Drug name & same Date of Service (DOS) was used already for the same PPID within the same CGID. This is the most common error occurrence in the edit spreadsheet for Pharmacy Event Forms. Alert the user if the NDC and the DOS are the same. But for the Drug Name route – alert the user if Drug Name and DOS and Strength are the same.

Q1: ENC_DATE is entered in format MM/DD/YYYY. Ranges allowed for ENC_DATE:

• MM = value for month (MM) should be between 1 and 12.

• DD = value for day (DD) should be 1-28 for all months; 29-30 for all months except month 2; 31 allowed only for months 1, 3, 5, 7, 8, 10, and 12; value 29 allowed for month 2 only in leap years

• YYYY = value for year (YYYY) should be 2022

DK/REF -- CONTINUE TO Q2

Q2: [IF R_RXIDTYPE = 1 (NDC) Q2a MUST HAVE A RESPONSE;

IF R_RXIDTYPE = 2 (Drug Name, Strength/Unit, & Dosage Form) NO RESPONSE REQUIRED. NEXT GO TO Q2b

DO NOT ALLOW DK/REF

Q2a: AHRQ receives an updated NDC table quarterly, but they only give it to us once per year so we are using the same table all year long.  We should receive an updated table at the start of production from AHRQ each year.

DO NOT ALLOW DK/REF

HARD CHECK THAT ONLY ENTRY ALLOWED IS 11 DIGITS, NO CHARACTERS OR SPACES ALLOWED.

When Q2a is COMPLETE, GO TO ConfirmNDC

For Q2a/NDC, add a hard check for the user’s entry against the table, ndc9_coding.ndc.

If the entered value matches a record in the table, go to ConfirmNDC.

If the entered value does not match any in the table, then display a hard check message:

The code you entered is not in our database of NDCs. Please verify your entry against the patient profile, or your POC. If your entry is correct, go back to the previous question, change answer to “Drug Name”, and record a drug name for this prescription.

Q1: EDIT SPECS FROM WESTAT

Data Item	Specifications	Action, if specification not met Item is missing if not present or legible, and not coded RF or N/A.
DATE FILLED DATE NUMBER ALL DATES Underline in 1st Rx on ea page.	Date column must be identified. Date may be labeled by the TRC.	Label the DATE field at the top of each page of the profile, if not labeled by the TRC. Circle the label.
		Label only the Date Filled. Ignore Date Written, Expiration Date, D/C Date or other dates that indicate something other than the date the prescription was filled.
	Month / Day / Year must be given or N/A = Not Ascertained or RF = Refused	If month or day is missing, code as N/A. If year is missing, Blue Sheet.
	Rx’s must be filled in 2022.	If there are no 2022 Rx’s, Blue Sheet.
		If a prescription was filled in a different year, cross out.
	Collect all 2022 fill dates for a medication.	Collect both original fills and refills.
	Prescriptions must be numbered to assist Cading to identify individual prescriptions.	Number the prescriptions near the date, if possible. Every fifth prescription may be numbered, unless it is necessary to number every prescription, for the sake of clarity.
	Profiles that contain data for only part of a year must be identified by the TRC. .	Code CL-IV as full year, unless “Partial Year” is indicated by TRC.
		If a TRC note or comment indicates that data was collected for only part of the year, code CL-IV for PARTIAL YEAR. See HOW TO CODE THE CL-IV, Chapter 5.3.
		If the dates on the profile indicate that only part of the year was covered, Blue Sheet, asking if the profile is for a PARTIAL YEAR.

Q2: NONE – THIS IS A NEW QUESTION FOR 2009

Q2a: EDIT SPECS FROM WESTAT

Data Item	Specifications	Action, if specification not met Item is missing if not present or legible, and not coded RF or N/A.
NDC – NATIONAL DRUG CODE NDC Underline in 1st Rx on ea page.	NDC numbers on the profile must be identified. NDC may be labeled by the TRC. 11 DIGITS, usually segmented as 5 digits – 4 digits – 2 digits. # # # # # - # # # # - # # or 99999999996 = (Compound) or 99999999997= (Refused) or 99999999999= (Not Ascertained)	Label the NDC field at the top of each page of the profile, if not labeled by the TRC. Circle the label.
		If NDC is missing, and no explanation, Blue Sheet.
		If not legible, Blue Sheet
		If Rx is a compound accept if a valid NDC code or NDC 99999-9999-96 is given. If Rx is a compound and no valid NDC code is given, Yellow Sheet
	NDCs of less than 11 digits or more than 11 digits need special handling. These are not valid NDCs.	If NDC is less than 11 digits (partial NDC) or more than 11 digits, flag for managerial review. Flag the invalid NDC with a wide Purple flag. Treat the invalid NDC as missing when editing other data elements.
	NDCs that start with 00000 need managerial review.	If the first 5 digits are 00000, Yellow Sheet. Treat as missing when editing other data elements.

NDC ROUTE

IF Q2 = 1 (NDC COLLECTED) ConfirmNDC

DCS: Please confirm that the drug names matches what is in the record (if specified in the record). If it does not, please go back and correct the NDC number entered.

The NDC you specified:

NDC: [FILL NDC]

Description1: [FILL NDC_NAME]

Description2: [FILL NDC_NAME2]

Is at least one of the above drug names correct?

YES

NO

Q3a. Quantity: N_QTY

Q4. How many days were supplied?

IF PRESCRIPTION WAS TO BE USED “AS NEEDED” ENTER 999

N_R_DAYSSUP

Q5. Patient Payment: 2N_PATPAY

Q5a. Were there any 3rd party payers? Q5a_Any3rdPARTY

YES

NO

PROGRAMMER NOTE

2018 UPDATE: Large patient payment check

• Patient payment >= $2,000 (“You have entered a patient payment amount >=$2000, please verify.”)

2018 UPDATE: Missing decimal soft check:

• Patient payment > $999 with 0 cents (“Large patient payment with 0 cents, please verify the decimal location.”)

• [Patient payment > $99 with 0 cents] AND [3rd Party payment >$0 and <$20 and <Patient Payment]

2018 UPDATE: Large quantity soft check

• Change Quantity >300 to >=300 (“You have entered quantity >=300, please verify”)

• Quantity >= 10 * Days Supplied (“Days supplied ([FILL N_R_DAYSSUP]) is high compared to quantity ([FILL N_QTY], please verify.”)

2018 UPDATE: Large days supplied soft check

• Days supplied >180 (“You have entered over 180 days, please verify.”)

ConfirmNDC: Do not allow DK/REF. If ConfirmNDC = 2 (NO), display hard check: “Please return and correct the NDC number entered.” If ConfirmNDC = 1, GoTo Q3a.

Q3a: Q3a ALLOW DK/RF. ALLOW INTEGER OR USE OF A DECIMAL POINT AND UP TO 3 DIGITS AFTERWARDS (E.G., 25, 3.5, 20.22, 0.333 ARE ALL VALID ENTRIES).

LIMIT THE USER’S ENTRY TO JUST 6 CHARACTERS.

RANGE = 0.001 to 999,999.999

Q4 -- DK/REF

Q5 – ADMINISTER SOFTCHECK FOR VALUES OVER $5,000

Q5 -- DK/REF -- CONTINUE TO Q5a.

Q5 NO SOFT CHECK WHEN RESERVE CODES USED.

Q5a – DK/REF – CONTINUE TO CallRouter

Q5a – If 1 (YES), GoTo Q6 (THPART). If 2 (NO), GoTo CallRouter.

Q3: EDIT SPECS FROM WESTAT

SPECIFICATIONS FOR DATA ELEMENTS – PRESCRIPTION

Quantity

Edit the Quantity, Quantity Unit and Dosage Form together. The Dosage Form determines whether a Quantity Unit is needed. The Dosage Form also determines whether the Quantity is valid.

Data Item		Specifications		Action, if specification not met Item is missing if it is not present or it is illegible, and it is not coded RF or N/A.
	QUANTITY QTY UNDERLINE EVERY QTY.		Quantity must be identified. The TRC may label the QTY.	Label the QTY field at the top of each page of the profile, if not labeled by the TRC. Circle the label
			NUMERIC or N/A = Not Ascertained or RF = Refused	If missing or not legible, or can’t be determined on the profile, write a Blue Sheet.
			Must be greater than 0.	If 0, write a Blue Sheet, asking if the prescription was filled. If negative, write a Yellow Sheet.
			Qty cannot be the number of containers. Quantity must be the contents of a container.	Review the quantity and the dosage form together. Are we collecting the number of containers rather than the contents? Blue Sheet, if the quantity is the number of containers. Ask for the quantity of the contents of the tube, bottle, vial, filled syringe, etc.
			The quantity of inhalers and dosepaks must be given as the contents of the inhaler or dosepak.	Blue Sheet, if the number of inhalers or dosepaks is given, instead of the contents of the inhaler or dosepak.
			Exception: The quantity of an Epipen may be accepted as the number of Epipens, if an NDC is given.	Do not ask for quantity of the contents in an Epipen, if an NDC is given. If an NDC is missing, write a Blue Sheet, asking for the NDC. If the NDC is N/A, write a Blue Sheet, asking for the QTY and Q/U of the contents of the Epipen.
			Quantities of 1 or 2 need special attention. Devices (vaporizer, brace, canes, etc.) can be dispensed in quantities of 1 or 2. Pills (tablets, capsules, etc.) can sometimes be dispensed in quantities of 1 or 2. This should not be confused with a 1 or 2 dosepaks, which contain multiple pills. For ointments, creams, drops, liquid, filled syringes (except Epipens) and other Dosage Forms that need a Quantity Unit, a Quantity of 1 or 2 is usually not acceptable.	Accept a Quantity of 1 or 2 for a device. Accept QTY of 1 or 2 for pills, unless it looks like the quantity is for one or two dosepaks, which may contain multiple pills. Blue Sheet, if there is a dosepak, asking for the Quantity of tables, capsules, etc. that it contains Blue Sheet for ointments, etc., asking if the Quantity on the profile is the number of containers (tubes, bottles, etc.) rather than the quantity of the contents. Ask for the quantity of the contents. Write a Yellow Sheet, if in doubt about a low quantity.

Q5: EDIT SPECS FROM WESTAT

1.6 SPECIFICATIONS FOR DATA ELEMENTS - PAYMENTS

For each prescription P-PAY, 3-T, and 3-PAY should be edited together.

P-PAY can help determine if we should expect a Third Party.

	Data Item	Specifications	Action, if specification not met Item is missing if not present or illegible, and not coded DK, RF or N/A.
PATIENT P-PAY Underline in 1st Rx.		Amount can be: $0.00 – $500.00 RF = Refused DK = There is a patient payment, but amount of payment is unknown N/A = Doesn’t know if there is a patient payment or not	If missing, Blue Sheet. If negative amount, Yellow Sheet. If not in range, Yellow Sheet. When P-PAY = $0.00 and 3-T = NONE, Blue Sheet, unless there is an explanation (who paid?). If there is an explanation, Yellow Sheet.
		If Patient Payment is $1.00 or less, expect the 3-T to be a public program, e.g., Medicaid or Other State/Local govt etc.	Yellow Sheet, if $1.00 P-Pay without a public program.
		Compare Patient payment to Third Party type. Both payments cannot be $0.00	If 3-T = NONE, and P=PAY is $0.00, Blue Sheet, unless there is an explanation. If there is an explanation, Yellow Sheet.
		Comments about P-PAY may need special handling. For example, a comment says Patient paid for prescription, but was reimbursed by Insurance.	If patient paid for prescription, but expected to be reimbursed, Yellow Sheet.
		Comment about P-Pay mentions “Sample.”	Yellow Sheet.

DRUG NAME ROUTE

IF Q2 = 3 (DRUG NAME COLLECTED)

SCREEN LAYOUT

Q2b. Drug Name - Search MED

DCS: PRESS <BACKSPACE> OR START TYPING IN THE DRUG NAME TO MAKE A SELECTION. IF YOU CANNOT LOCATE THE CORRECT DRUG IN THE TABLE, CANCEL OUT OF THE SEARCH TABLE AND ENTER <F6> FOR THE DRUGLOOKUP FIELD.

Q2b_1

Compound drug? D_COMPOUND

YES

NO

Durable Medical Equipment (DME?) DME

YES

NO

MJ? MJ

YES

NO

Q2c. Strength STRENGTH

Q2d. Unit STRGTHUNIT

Other specify STRGTHUNITOT

Q2c1. Strength 2 STRENGTH2

Q2d2. Unit 2 STRGTHUNIT2

Other specify STRGTHUNITOT2

Q2e. Dosage Form DOS_FORM

Other Specify DOS_FORMTXT

Q3a. Quantity D_QTY

Q3b Quantity Unit QTYUNIT

OTHER, PLEASE SPECIFY QTYUNITOTHER

Q4. How many days were supplied?

DCS: IF PRESCRIPTION WAS TO BE USED “AS NEEDED” ENTER 999

D_R_DAYSSUP

Q5. Patient Payment: D_PATPAY

Q5a. Were there any 3rd party payers? $Q4_Any3rdPARTY

2018 UPDATE: Add Blaise trigram lookup for drug name. Drug name will populate as from directory. Drug name text can be edited.

2018 UPDATE: Move the name lookup question to before the MED question. Do not populate the NDC but use it as “shortcut” for the DCS to type in the editable MED string.

2018 UPDATE: Add the strength unit “mg/Act”.

2018 UPDATE: Changes for DME (Durable Medical Equipment): Allow HCPCS, if available, rather than NDC codes in the response option box. Continue to require drug name. NDC will not be available on the records for DME.

2018 UPDATE: Days supplied and quantity inconsistency check

• Days supplied >= [10 * Quantity AND Quantity is a whole number >6 AND Quantity ne 10] AND [NDC entered OR [Quantity Unit = (13,14,15,20,24,25) or Dosage form = 7,8,16,22,23, 32,39,45,46,48,51,53,54,60,146)]].

• If true, display: “Quantity is high ([FILL D_QTY]) compared to days supplied ([FILL D_R_DAYSSUP]), please verify.”

2018 UPDATE: Dosage form and quantity unit inconsistency check

• On the drug name path (r_rxidtype=2), Quantity unit is a pill but Dosage form is not a pill (quantity unit =13,14,15,20,24,25 and dosage form ne -1,146,199)

• If true, display: “Quantity Unit is a pill, but Dosage Form is not a pill. Please review.”

• On the drug name path (r_rxidtype=2), Dosage form is pill but quantity unit is not (quantity unit ne -1,12, 13,14,15,20,24,25 and dosage form = 146).

• If true, display: “Dosage Form is a pill, but Quantity Unit is not a pill. Please review.

2016 UPDATE: Add a “MJ” question after the Durable Medical Equipment question. Add a Marijuana question in addition to the DME and Compound option when entering medication by drug name. Adding the question would allow us to skip out of data elements not available and flag the record as medical marijuana. We anticipate the quantity of these records to keep increasing.

When Q2b_1 DME or MJ = 1 (YES) then the following variables can be skipped without activating the error message:

Strength, Strength Unit, and Dosage Form

Q2b: Drug lookup function occurs in DrugLookup field. The text selected by the user in the DrugLookup field populates into the MED field. The text in MED can be edited. Text in DrugLookup cannot be edited.

Q2C: WHEN RECORDING STRENGTH, ENTER A WHOLE NUMBER OR A FRACTIONAL VALUE UP TO 3 DECIMAL POINTS. VALID ENTRIES INCLUDE 15, 3.5, 2.25, 0.333 There are occasions where we have drugs with multiple concentrations and it will be easier to combine the strengths into single entries as much as possible. For example : Robitussin DM - if you enter the drug by the brand name it will not provide you with a strength. You must F6 Q2C  and

Q2D . But if the same medication is listed on the records as generic  (Guaifenesin 100/5 Dextromethorphan 10/5)  here is how you should enter it :   Q2C 100/5 Q2D mg/ml  and Q2C2  10/5 Q2D2 mg/ml.  Do not include any spaces when recording strenth.

Allow for unlimited slashes in response.

Q2d: Note: WHERE NECESSARY, YOU MAY ENTER A SECOND STRENGTH AND UNIT FOR EXAMPLE TO DESCRIBE A SOLUTION OR CONCENTRATION (e.g., 7 mg/5 ml). OTHERWISE SKIP TO Q2e DOSAGE FORM.

Q3a: WHEN RECORDING QUANTITY, ENTER A WHOLE NUMBER OR A FRACTIONAL VALUE UP TO 3 DECIMAL POINTS. VALID ENTRIES INCLUDE 100, 15, 3.5, 2.25, 0.333. Valid range = 0.001 to 99999.999.

NOTE 1: QUANTITY SHOULD REFLECT THE CONTENTS OF A CONTAINER, NOT THE NUMBER OF CONTAINERS.

EXCEPTION: IF NDC PROVIDED, THEN NUMBER OF EPIPENS CAN BE RECORDED FOR QUANTITY, AS OPPOSED TO QUANTITY OF EPIPEN CONTENTS.
 

NOTE 2: FOR A DEVICE, ACCEPT A QUANTITY OF 1 OR 2.

NOTE 3: FOR PILLS, A QUANTITY OF 1 OR 2 IS ACCEPTABLE BUT CONSIDER EXCEPTION BELOW BEFORE ENTRY.

EXCEPTION: IF IT APPEARS THE QUANTITY IS FOR ONE OR TWO DOSEPAKS CONTAINING MULTIPLE PILLS, THEN RECORD THE QUANTITY OF TABLETS, CAPSULES, ETC., THAT EACH DOSEPAK CONTAINS.

NOTE 4: FOR INHALERS, OINTMENTS, CREAMS, DROPS, LIQUID, FILLED SYRINGES (EXCEPT EPIPENS) AND OTHER DOSAGE FORMS NEEDING A QUANTITY UNIT, ASK FOR THE QUANTITY OF THE CONTENTS.

PROGRAMMER NOTES

Q2b - DK/REF -- CONTINUE TO Q2c/d

Q2b_1 – DK/REF NOT ALLOWED FOR D_COMPOUND AND DME. IF MJ = DK/REF OR 1 (Yes), GO TO Q3a D_QTY. IF MJ = 2, GO TO Q2c STRENGTH.

Q2c/d - DK/REF -- CONTINUE TO Q2e

After Q2e DOS_FORM is entered, display Confirm screen. Display text, “Confirm the selection: Dosage form = [FILL DOS_FORM_DE]. Is this correct?” If NO, DK/REF, display hard check: “If not correct, you must search again for the correct dosage form.” If Confirm = YES, GoTo DOS_FORMTXT if DOS_FORM = 199 (Other specify). Else, GO TO Q3a.

Q3a D_QTY ALLOW DK/RF. ALLOW INTEGER OR USE OF A DECIMAL POINT AND UP TO 3 DIGITS AFTERWARDS (E.G., 25, 3.5, 20.22, 0.333 ARE ALL VALID ENTRIES).

LIMIT THE USER’S ENTRY TO JUST 6 CHARACTERS AND ADD A SOFT-CHECK MESSAGE FOR NUMBERS OVER 300, “You have entered quantity >= 300, please verify.”

When MED is complete, send user to Q2b_1 D_COMPOUND.

IF Q2b_1 D_COMPOUND = 1 (YES) GO TO DME AND MJ, BUT SKIP Q2c STRENGTH, Q2d STRGTHUNIT, Q2c1 STRENGTH2, AND Q2d2 STRGTHUNIT2; IF D_COMPOUND = 1, AFTER MJ, GO TO DOS_FORM_DE.

IF Q2b_1 DME = 1 (YES) GO TO Q3a (D_QTY). ELSE, GO TO MJ.

Q2c/d UNIT-- 19 strength units for the interviewer to choose from. Strength unit options are listed below. One option should allow the selection of “Other - specify” and allow entry of a response as text (variable name=STRGTHUNITOTHER)

1. Mg. 11. mg/mg

2. mcg 12. mg/hr

3. meq 13. meq/ml

4. mg/ml 14. mcg/mL

5. g, gm 15. u/gm

6. GR, gr 16. u/Ml

7. % 17. IU

8. Ml, ml, mL 18. Other - specify

9. cc 19. mg/Act

10. mg/mcg 20. Mcg/dose

21. Mcg/Act

Q2C AND Q2C2 SHOULD NOW ALLOW INTEGER ENTRY, OR USE OF A DECIMAL POINT AND UP TO 3 DIGITS AFTERWARDS (E.G., 25, 3.5, 20.22, 0.333 ARE ALL VALID ENTRIES). ALLOW TWO STRENGTHS (SEPARATED BY A SLASH) TO BE CAPTURED IN BOTH Q2C AND Q2C2. FOR EXAMPLE:

Q2C 100/5

INTEGER ENTRY, OR USE OF A DECIMAL POINT AND UP TO 3 DIGITS AFTERWARDS (E.G., 25, 3.5, 20.22, 0.333 ARE ALL VALID ENTRIES) / INTEGER ENTRY, OR USE OF A DECIMAL POINT AND UP TO 3 DIGITS AFTERWARDS (E.G., 25, 3.5, 20.22, 0.333 ARE ALL VALID ENTRIES). NO SPACES ALLOWED IN THE ENTRY

Allow for unlimited slashes in response.

Q2c STRENGTH and STRENGTH2 fields are text field allowing up to 50 characters.

Q2e DOSAGE FORM – The DOSAGE FORMS list below provides options to be available in a searchable lookup feature. The options should also allow the selection of “other” and enter a response as text. The “other” text will be recorded in new variable DOS_FORMTXT. See below for list of dosage forms. Dosage forms are to appear in a lookup table/list with the default order being alphabetical, with an option to order by Code. A Search function allows the user to locate dosage forms by typing the first several characters of the dosage form. Once a dosage form option is selected, it populates the option text in field DOS_FORM_DE, and populates DOS_FORM with the number associated with that option. Also new for Option Yr1 we deleted 63 ZPak and add 146 Gel caps/liquid gels. Future years should not reintroduce 63 as a data value for any dosage form; that value is being retired.

DOSAGE FORMS

Reference spreadsheet Op_DSG_2010.csv. This reflects the deletion of 63 ZPak and the addition of 146 Gel caps/liquid gels. Dosage forms are to appear in a lookup table/list with the default order being alphabetical, with an option to order by Code. A Search function allows the user to locate dosage forms by typing the first several characters of the dosage form.

-Select one -	0	COT-Cotton	14	PAS-Paste	128
TAB-Tablet	48	CRY-Crystal	15	Patches	36
CAPL-Caplets	7	DIA-Diaphragm	18	PDI-Powder for injection	129
CAP-Capsule	8	Disc	19	PDR-Powder for reconstitution	130
CER-Tablet, extended release	54	DRE-Dressing	21	PEL-Pellets	37
SOL-Solution	138	Ear drops	108	Pen	151
DEV-Device	17	ELI-Elixir	110	POD-Pod	38
GER -Granule, extended release	113	Emulsion	149	POW-Powder	131
SUS-Suspension	140	Eye drops	109	Powder for solution	150
ECT-Enteric-coated tablet	23	FLA-Flake	25	PRO-Prophylactic	132
ECC-Enteric-coated capsule	22	FIL-Film	24	Pulvule	39
SPR-Spray	139	Film Extended Release	64	Rinse	133
Diskus	20	FOA-Foam	111	RUB-Rub	134
SYR-Syrup	141	GAU-Gauze	26	Sal-Salve	135
CRE-Cream	106	GEL-Gel/jelly	112	SER-Suspension, extended release	136
ARO-Aerosol solid	2	GEF-Granules effervescent	147	SET-Set	40
INH-Inhalant	118	GELC - Gel caps/liquid gels	146	SHA-Shampoo	137
INH-Inhaler	117	GFS-Gel forming solution	114	Soap	41
INJ-Injectable	119	GRA-Granules	115	SPG-Sponge	42
Drops	107	GRR-Granules for reconstitution	116	SRN-Syringe	44
CTB-Chewable tablet	16	GUM-Gum	27	Strips	43
AER-Aerosol liquid	102	ICR-Insert controlled release	65	SUP-Suppository	46
Sublingual	45	IMP-Implant	28	SWA-Swab	47
ACC-Accessory Aerosol	101	IV-Injection	120	TAM-Tampon	49
ARA-Aerosol liquid w/adapter (Inhaler)	1	Jelly	121	TAP-Tape	50
ARD-Aerosol solid w/adapter	103	KIT-Kit	29	TCP-tablet coated particles	51
BAL- Balm	104	Lancets	30	TDM-Film, extended release	52
BAN- Bandage	3	LEA-Leaf	31	TDM-Transdermal	59
BAR-Bar	4	LIQ-Liquid	122	TEF-Tablet, effervescent	53
BLO-Block	5	LOT-Lotion	123	Test Strips	56
CAK-Cake	6	LOZ-Lozenge/troche	32	TES-Test	55
CAT-Catheter	9	LUM-Lump	33	THE-Thermometer	57
CHI-Chip	10	NDL-Needle	34	TIN-Tincture	58
CLA-Clamp	11	NEB-Nebulizer	124	Topical – Unspecified	148
CNT-Concentrate	105	Nose Drops	125	Troche	60
CON-Connector	13	OIL-Oil	126	Vaginal ring	152
Condom	12	OIN-Ointment	127	WAF-Wafer	61
		PAD-Pad	35	Wash	144
				WAX-Wax	145
				Wrist brace	62
				OTHER-Other specify	199

Q3b Quantity Unit

Quantity Units should be displayed as options in the following order:

Milliliter (1) “Ml, ml, mL – milliliter”

,gram (3) “G, GM – gram”

,grain (4) “GR – grain”

,ounce (5) “OZ – ounce”

,pint (6) “PT – pint”

,quart (7) “QT – quart”

,gallon (8) “GAL – gallon”

,tablets (13) “TAB – tablets”

,capsules (14) “CAP – capsules”

,caplets (15) “CAP – caplets”

,lancets (16) “lancets”

,monitor (17) “monitor”

,teststrips (18) “test strips”

,syringes (19) “SRN – syringes”

,lozenges (20) “LOZ – lozenges”

,inhalations (21) “INH – inhalations”

,needles (22) “NDL – needles”

,alc_pads (23) “alcohol pads”

,gelcaps (24) “GELC – gel caps”

,suppositories (25) “SUP – suppositories”

,patches (26) “PA – patches”

,device (27) “Device”

,gumpieces (28) “Gum pieces”

,pads (29) “Pads”

,swabs (30) “Swabs”

,troches (31) “Troches”

,blisters (32) “Blisters”

,inhalers (33) “Inhalers”

,penneedles (34) “Pen needles”

,other (12) “Other”

Q3b Quantity Unit -- The quantity unit is only required for certain dosage forms that cannot be counted (e.g., liquids, creams, lotions, etc.). Program the instrument so that the interviewer/abstractor is prompted to collect quantity unit for the dosage forms indicated by a numeric value of 100 or higher in the Dosage Forms list (i.e., if DOS_FORM >= 100, display QTYUNIT; if DOS_FORM <100, do not display QTYUNIT).

Q3b -- DK/REF -- CONTINUE TO Q4

Q4 -- DK/REF -- CONTINUE TO Q5

Q5 – ADMINISTER SOFTCHECK FOR VALUES OVER $5,000

Q5 -- DK/REF -- CONTINUE TO Q5a.

Q5a – DK/REF – CONTINUE TO EXIT SCREEN.

Q5 NO SOFT CHECK WHEN RESERVE CODES USED.

EDIT SPECS FROM WESTAT

Data Item	Specifications		Action, if specification not met Item is missing if it is not present or it is illegible, and it is not coded RF or N/A.
MEDICATION NAME 1 NAME Underline in 1st Rx on ea page.	Drug name on profile must be identified. The TRC may label the Drug Name.		Label the NAME field at the top of each page of the profile, if not labeled by the TRC. Circle the label.
	TEXT or RF = Refused or N/A = Not Ascertained		ONLY NEEDED WHEN THERE IS NOT A VALID NDC.. If medication name is required but missing, write a Blue Sheet.
STRENGTH/STRENGTH UNIT S/U Underline in 1st Rx on ea page.	Strength and Strength Unit on profile must be identified. The TRC may label the S/U.		Label the S/U field at the top of each page of the profile, if not labeled by the TRC. Circle the label.
	NUMERIC (Strength)/TEXT (Strength Unit) or RF = Refused or N/A = Not Ascertained		Only required if there is not an NDC. If required but the Strength/Unit is missing, illegible or incomplete, Blue Sheet. Note: the entire S/U must be given. Blue Sheet if required and only part of the S/U appears on the profile
			If the Strength Unit is not on the range list below, Yellow Sheet. If S/U is grains (or GR or gr), note this on the Yellow Sheet.
	RANGE OF STRENGTH UNITS (See Range Sheet for Strength Units, Chapter 3.4)
	mg mg. mcg meq mg/Ml g, gm GR, gr	% Ml, ml, mL cc mg/mcg mg/mg mg/hr		meq/Ml mcg/mL u/gm u/Ml IU
DOSAGE FORM DSF UNDERLINE EVERY DSF.	Dosage Form on profile must be identified.		Label the DSF field at the top of each page of the profile. Circle the label.
	TEXT or RF = Refused or N/A = Not Ascertained See range sheet, Chapter 3.5, for examples.		Only required if there is not an NDC. If required but missing, Blue Sheet. If required but not legible, Blue Sheet. If a Dosage Form is not on the range sheet, Yellow Sheet.
	Partial Dosage Forms are not acceptable if no valid NDC given. For example, don’t accept TA for TAB.		If a partial DSF is given, and no NDC, Blue Sheet.
	Take the item name as the Dosage Form if it is a product. For example: if profile says Back Brace, DSF is Brace.		Accept.
	Do not take containers (vials, bottles, tubes, etc.) as Dosage Forms. Do not take Each (ea) as a Dosage Form.		If a container or “each” is given as a DSF, Blue Sheet unless there is a valid NDC.
	The Dosage Forms Diskus or Blister need managerial review.		Yellow Sheet if DSF is blister or discus. Yellow Sheet if medication is Advair diskus, Serevent diskus, or Flovent Rotadisk.

EDIT SPECS FROM WESTAT

SPECIFICATIONS FOR DATA ELEMENTS – PRESCRIPTION

Quantity, Quantity Unit and Dosage Form

Edit the Quantity, Quantity Unit and Dosage Form together. The Dosage Form determines whether a Quantity Unit is needed. The Dosage Form also determines whether the Quantity is valid.

Data Item		Specifications		Action, if specification not met Item is missing if it is not present or it is illegible, and it is not coded RF or N/A.
	QUANTITY QTY UNDERLINE EVERY QTY.		Quantity must be identified. The TRC may label the QTY.	Label the QTY field at the top of each page of the profile, if not labeled by the TRC. Circle the label
			NUMERIC or N/A = Not Ascertained or RF = Refused	If missing or not legible, or can’t be determined on the profile, write a Blue Sheet.
			Must be greater than 0.	If 0, write a Blue Sheet, asking if the prescription was filled. If negative, write a Yellow Sheet.
			Qty cannot be the number of containers. Quantity must be the contents of a container.	Review the quantity and the dosage form together. Are we collecting the number of containers rather than the contents? Blue Sheet, if the quantity is the number of containers. Ask for the quantity of the contents of the tube, bottle, vial, filled syringe, etc.
			The quantity of inhalers and dosepaks must be given as the contents of the inhaler or dosepak.	Blue Sheet, if the number of inhalers or dosepaks is given, instead of the contents of the inhaler or dosepak.
			Exception: The quantity of an Epipen may be accepted as the number of Epipens, if an NDC is given.	Do not ask for quantity of the contents in an Epipen, if an NDC is given. If an NDC is missing, write a Blue Sheet, asking for the NDC. If the NDC is N/A, write a Blue Sheet, asking for the QTY and Q/U of the contents of the Epipen.
			Quantities of 1 or 2 need special attention. Devices (vaporizer, brace, canes, etc.) can be dispensed in quantities of 1 or 2. Pills (tablets, capsules, etc.) can sometimes be dispensed in quantities of 1 or 2. This should not be confused with a 1 or 2 dosepaks, which contain multiple pills. For ointments, creams, drops, liquid, filled syringes (except Epipens) and other Dosage Forms that need a Quantity Unit, a Quantity of 1 or 2 is usually not acceptable.	Accept a Quantity of 1 or 2 for a device. Accept QTY of 1 or 2 for pills, unless it looks like the quantity is for one or two dosepaks, which may contain multiple pills. Blue Sheet, if there is a dosepak, asking for the Quantity of tables, capsules, etc. that it contains Blue Sheet for ointments, etc., asking if the Quantity on the profile is the number of containers (tubes, bottles, etc.) rather than the quantity of the contents. Ask for the quantity of the contents. Write a Yellow Sheet, if in doubt about a low quantity.

SPECIFICATIONS FOR DATA ELEMENTS -- PRESCRIPTION

Data Item	Specifications	Action, if specification not met Item is missing if it is not present or it is illegible, and it is not coded RF or N/A.
QUANTITY UNIT Q/U UNDERLINE EVERY Q/U.	Quantity Unit on the profile must be identified, if present. The TRC may label the Q/U.	Label the Q/U field at the top of each page of the profile, if the TRC has not labeled it. Circle the label. Be careful that the S/U is not labeled as the Q/U.
	Q/U measures the amount of medication dispensed. It is only needed for certain Dosage Forms that cannot be counted.	See the Dosage Form range sheet, Chapter 3.5. Pills, and other items that can be counted, will not need a Q/U. Liquids, creams, lotions, etc. will need a unit of measurement to complete the quantity information.
	TEXT	If the Quantity Unit is Grains (GR, gr), Yellow Sheet. If the Quantity Unit is not on the range sheet, Yellow Sheet.
	Range of Quantity Units (See Range Sheet for Quantity Unit, Chapter 3.6)
	Ml, mL, ml mg g, gm gr, GR (Yellow Sheet) oz pt	qt gal MCL MCM MCN	Tablets Capsules Caplets
	If the Strength Unit is ML or %, a Quantity Unit will be needed.	Do not take a the S/U for the Q/U.
	If required, the Q/U can’t be missing.	If the Q/U is not given, and there is no other reason for a Blue Sheet, see if the Q/U can be added according to the Guidelines For Adding a Quantity Unit on the next page. If the Q/U is missing, and we are sending a Blue Sheet out for other items, do not add the Q/U. Add the question to the Blue Sheet. If there is no NDC, do not add Q/U.

IF THERE IS NO NDC, DO NOT ADD THE Q/U. WRITE A BLUE SHEET FOR THE NDC AND THE Q/U.

IF THERE IS ANY OTHER REASON TO SEND A BLUE SHEET, DO NOT ADD THE Q/U. ASK FOR THE Q/U ON THE BLUE SHEET.

1.5.1 Guidelines For Adding A Quantity Unit– When Q/U Is Missing

There must be a valid NDC. There must be an appropriate Dosage Form. There must be a Quantity. The Q/U must be the only reason for a Blue Sheet. Edit the entire case, making a Blue Sheet for Q/U as usual. After all profiles are edited, if the only reason for the Blue Sheet is Q/U, editors may be able to add the Q/U. To add a Q/U, review the NDC, DSF and QTY and follow the guidelines.	DSF IS LIQUID If the Dosage Form is a liquid (and is not an inhaler), Quantity Units may be added by the editor in some situations. Liquids, Solutions, Suspensions, Syrups, Elixers and Drops usually have a Q/U = Ml QTY FOR LIQUID The Quantity should be compatible with the unit of measurement. For example, for Liq, Sus, Syr, and Eli, common quantities are 240 mL, 480 mL, 4000 mL. Drops, Solutions and Liq may also have smaller quantities with mL. If Quantity is 8 or 16 or 32, the measurement may be in ounces. Do not code as mL.	IF THERE IS AN NDC AND A QTY Editors can add mL if there is an NDC and the quantity is compatible with metric measurements.
		If the Quantity looks like it is measured in ounces, write a Yellow Sheet. Flag with a wide purple flag. If there is no NDC, or no QTY, Blue Sheet for the Q/U as well as for the NDC and/or QTY. If the Quantity looks like it is measured in ounces, write a Yellow Sheet. Flag with a wide purple flag. Write a Yellow Sheet if in doubt.
	DSF IS CREAM If the Dosage Form is cream, the Q/U may be added by the editor in some situations. Creams usually have a Q/U of gm. THIS DOES NOT APPLY TO OINTMENTS OR GELS. QTY FOR CREAM The Quantity should be compatible with the unit of measurement. For example, common quantities of creams are 15gm, 30gm, 45 or 60, although smaller quantities may also be measured in grams. If the quantity is1 or 2 or 4 or 6 or 8, the measurement may be in ounces. Do not code as gm if you suspect that the Q/U may be ounces.	IF THERE IS AN NDC AND A QTY Editors can add gm if there is an NDC and the quantity is compatible with metric measurements.
		If the quantity looks like it is measured in ounces, write a Yellow Sheet. Flag with a wide purple flag. If there is no NDC, or no QTY, Blue Sheet for the Q/U as well as for the NDC and/or QTY. Blue Sheet for a missing Q/U if the DSF is ointment or gel, or other similar forms. Write a Yellow Sheet if in doubt.
	DSF IS INHALER If the Dosage form is Inhaler or Aerosol, further review is needed, if Q/U is missing.	IF THERE IS AN NDC AND A QTY Flag with a wide purple flag, and Yellow Sheet.
		If there is no NDC, or no QTY, Blue Sheet for the Q/U as well as for the NDC and/or QTY.

EDIT SPECS FROM WESTAT

1.6 SPECIFICATIONS FOR DATA ELEMENTS - PAYMENTS

For each prescription P-PAY, 3-T, and 3-PAY should be edited together.

P-PAY can help determine if we should expect a Third Party.

	Data Item	Specifications	Action, if specification not met Item is missing if not present or illegible, and not coded DK, RF or N/A.
PATIENT P-PAY Underline in 1st Rx.		Amount can be: $0.00 – $500.00 RF = Refused DK = There is a patient payment, but amount of payment is unknown N/A = Doesn’t know if there is a patient payment or not	If missing, Blue Sheet. If negative amount, Yellow Sheet. If not in range, Yellow Sheet. When P-PAY = $0.00 and 3-T = NONE, Blue Sheet, unless there is an explanation (who paid?). If there is an explanation, Yellow Sheet.
		If Patient Payment is $1.00 or less, expect the 3-T to be a public program, e.g., Medicaid or Other State/Local govt etc.	Yellow Sheet, if $1.00 P-Pay without a public program.
		Compare Patient payment to Third Party type. Both payments cannot be $0.00	If 3-T = NONE, and P=PAY is $0.00, Blue Sheet, unless there is an explanation. If there is an explanation, Yellow Sheet.
		Comments about P-PAY may need special handling. For example, a comment says Patient paid for prescription, but was reimbursed by Insurance.	If patient paid for prescription, but expected to be reimbursed, Yellow Sheet.
		Comment about P-Pay mentions “Sample.”	Yellow Sheet.

SCREEN LAYOUT

Q6. Type of 3rd Party Payer  THPART#

Other Specify Source THPARTOTH#

Q7. 3rd Party Payment THPARTAMT#

DCS: IF PATIENT PAYMENT WAS $1 OR LESS,

EXPECT THE 3^rd PARTY PAYER TO BE A

PUBLIC PROGRAM, E.G., MEDICAID OR

OTHER STATE/LOCAL GOVT, ETC.

Any more 3^rd Party Payers? Q7_AnyMore

1. YES

2. NO

PROGRAMMER NOTES

2018 UPDATE: Large third party payer amount soft check

• Third party payer amount >= $12,000 (“You have entered a 3^rd party payment amount >=$12,000, please verify.”)

2018 UPDATE: Merge the two “are there any 3rd party payers” question into a single question. Display all 3rd party payment information together in the instrument grid.

Q6/Q7 – ALLOW A MAXIMUM OF TWO 3^rd PARTY PAYERS. AFTER THPARTAMT2, GO TO CallRouter.

Q6 -- AHRQ provided an additional category for OY2, namely, “Indigent/sliding scale”, to describe third party payers in a drop-down list in variable THPART#. Upon selecting “Other, Specify” the instrument should allow the user to enter text in a newly specified box called THPARTOTH#. There are several new responses in Option Yr 1; they should be displayed above the Other response option.

₁ Private insurance

₂ Medicaid/CHIP

₃ Other State/Local Govt (also Public-State, Public-Local)

₄ D: Medicare/Medicare RX-Part D

₅ Other Federal (also Public-Federal)

₆ Worker’s Comp

₇ VA/ChampVA

₈ Tricare/Military

₁₃ Manufacturer’s Program

₁₄ Publicly-funded Clinic

₁₇ Kaiser (Don’t know if private or public)

₁₈ Public (Don’t know if Medicare/aid, State/Local, or Federal)

₁₉ Indian Health Service

₂₁ Free/Discount/Write-off/No cost/Discount drug cards

₂₆ Indigent/charity/sliding scale/hospital internal

₂₇ Pharmacy Benefit Management Company (PBM)

₂₈ Manufacturer’s Coupon

₉₁ Other, Specify

Q6/Q7 – is a question loop that will require

1. A HISTORY TABLE to display responses already collected.

2. A question (Q7_AnyMore) to appear after each iteration of the question that reads:

Any more 3^rd party payers? YES=1 NO=2

Q7 --$0 is allowable

Q6 -- DK/REF -- CONTINUE TO Q7.

Q7 – DK/REF – CONTINUE TO Q7_AnyMore SCREEN.

Q6 – THPARTOTH# text field allows up to 30 characters

Q7: NO SOFT CHECK WHEN RESERVE CODES USED.

EDIT SPECS FROM WESTAT

1.6 SPECIFICATIONS FOR DATA ELEMENTS - PAYMENTS

For each prescription P-PAY, 3-T, and 3-PAY should be edited together.

P-PAY can help determine if we should expect a Third Party.

	Data Item	Specifications		Action, if specification not met Item is missing if not present or illegible, and not coded DK, RF or N/A.
THIRD PARTY TYPE 3-T Underline in 1st Rx.		NONE = No THIRD PARTY involved DK = There is a THIRD PARTY involved but don’t know type N/A = Don’t know if there is a THIRD PARTY involved or not		If 3-T is not on range sheet, Yellow Sheet. If there is a source then there must be an answer for payment; Blue Sheet if payment is missing and the TRC has not indicated DK or RF. If Third Party Pay is $0.00 for a prescription, code the prescription as 3-T = NONE.
		Ranges for Third Party Type
		Private Medicaid Other State / Local Govt (also accept Public-State or Public-Local) Medicare Other Federal (also accept Public – Federal) Worker’s Comp VA Champus / ChampVA (also accept Tricare, but change to Tricare/Champus)	PCS (don’t know if private or public) DPS (don’t know if private or public) Manufacturer’s Program Publicly-funded Clinic Planned Parenthood Student Health Center Kaiser (don’t know if private or public) Public (don’t know if Medicare, Medicaid, State/Local, or Federal) Military Indian Health Service 91, Other (specify)
		Compare 3-T to P-Pay and 3-PAY. If 3-Pay is $0.00 for a prescription, then 3-T is NONE.	When 3-Pay is $0.00 for a prescription, code that prescription as 3-T = None.
		If 3-T is NONE, P-Pay cannot be $0.00.	If 3-T is NONE and P-Pay is $0.00, write a Blue Sheet to find out who paid, unless there is an explanation If an explanation is given, write a Yellow Sheet
		If 3-T is DK or NA or NONE, the name of the provider should not indicate a Third Party type that is on the range list. For example, does the name indicate Kaiser, Student Health Center, VA or military, Indian Health, or Planned Parenthood?	If the name of the provider indicates a choice on the Range Sheet for Third Party types, Yellow Sheet. Examples: Planned Parenthood, VA, Student Health Center, Kaiser
		Medicare as a Third Party needs special handling. Medicare is appropriate as a Third Party in limited situations: Expect the customer to be 62 or over, or to have certain conditions that are covered by Medicare, like ESRD or Diabetes.	Yellow Sheet, if Medicare is the Third Party type and patient is not 62 years of age (review the Customer Data Form). Accept Medicare payment for Diabetic supplies.
THIRD PARTY TYPE 3-T 3-T is OTHER THIRD PARTY 1,2,3 OTHER SPECIFY This field only appears when Payer Source = 91(Other/Specify)		TEXT Used when 3-T is Other/Specify. Used when the 3-T is not on the Third Party range sheet.	Only required if Source is Other Specify If Other is indicated, but no source is specified, Blue Sheet. If Other/Specify is given, Yellow Sheet.
		Tricare is acceptable as a Third Party type. This is an updated name for Champus.	Do not code as 91 (Other Specify). Change the 3-T to TRICARE/CHAMPUS, so that it will be Caded correctly.

THIRD PARTY 1,2,3 PAYMENT 3-PAY Underline in 1st Rx.	$0.01 – $5,000.00 RF = Refused DK = Knows there is a THIRD PARTY payment, but not amount N/A = Doesn’t know if there is a THIRD PARTY payment or not	If 3-Pay is not identified, Blue Sheet.
		If amount is greater than $5000, Blue Sheet to verify the amount, unless there is a comment confirming the amount.
		If 3-PAY is $0.00, and P-Pay is also $0.00, write a Blue Sheet for an explanation (who paid?). If an explanation is given, write a Yellow Sheet.
		If negative amount, write a Yellow Sheet.
	If 3-PAY is $0.00, THIRD PARTY Type is NONE.	If profile indicates that the 3-PAY for a prescription is $0.00, editors will code 3-T as NONE for that prescription.
	If 3-Pay is N/A, 3-T should be N/A	Yellow Sheet, if Third Party is Given or DK or NONE, but the 3-PAY is N/A. Yellow Sheet, if 3-Pay is Given, or DK or NONE, but the Third Party is N/A.
	Compare Patient payment to Third Party type. Both payments cannot be $0.00	If 3-T = NONE, and P=PAY is $0.00, write a Blue Sheet, unless there is an explanation. If there is an explanation, write a Yellow Sheet.
	Notes on the profile may indicate that 3-PAY can be determined by a calculation. For example, the TRC writes that 3-PAY = PRICE – CO-PAY.	Editors will calculate the 3-Pay following the directions given by the TRC. In the example at left, editors would subtract the CO-PAY from the PRICE to determine the 3-PAY.
	Discounts or Discount cards need special handling.	If discount or discount card is mentioned, write a Yellow Sheet.
	Samples need special handling.	Write a Yellow Sheet, when "Sample" or "Free Sample" is given as an explanation of 3-PAY.

THREE MAIN PATHS IN PHARMACY

NDC

Answer Q2=1 (NDC path)

Answer Q2a (actual code)

Answer Q3a (quantity)

Answer Q4 (days supplied)

Answer payments questions, allowing up to two 3^rd party payers

NON-NDC

TYPE A: solutions, gels and others with asterisk on 3.5 RANGE SHEET OF STANDARD DOSAGE FORMS

Answer Q2=2 (non-NDC path)

Answer Q2b (actual drug name)

Answer Q2c / Q2d, Q2c1 / Q2d1 (Strength/Strengthunit)

Answer Q2e (solutions, gels or other dosage form for which an asterisk appears in specs)

Answer Q3a (quantity)

Answer Q3b (quantity unit)

Answer Q4 (days supplied)

Answer payments questions, allowing up to two 3^rd party payers

NON-NDC

TYPE B: tablets, capsules, and others without asterisk on 3.5 RANGE SHEET OF STANDARD DOSAGE FORMS

Answer Q2=2 (non-NDC path)

Answer Q2b (actual drug name)

Answer Q2c / Q2d, Q2c2 / Q2d2 (Strength/Strengthunit; Strength2/Strengthunit2)

Answer Q2e (tablets, capsules or other dosage form for which no asterisk appears in specs)

Answer Q3a (quantity)

Answer Q3b (quantity unit)

Answer Q4 (days supplied)

Answer payments questions, allowing up to two 3^rd party payers

Notes on recording drug strength

The original specifications implied just one field each for strength and strength unit (Q2c and Q2d). Those two fields successfully record most drug strengths, as well as concentrations for which the volume denominator is 1 unit. For example:

Reported 2c. Strength 2d. Strengthunit

25 mL 25 mL

150 mg 150 mg

35 mcg/mL 35 mcg/mL

1000 IU 1000 IU

However some respondents may report a concentration with denominator other than 1. We added variables Strength2 and Strengthunit2 to achieve this. The user would use four fields to record that data. Examples below how users would record several known Albuterol dosages.

Reported 2c. Strength 2d. Strengthunit 2c2. Strength2 2d2. Strengthunit2

2 mg/5mL 2 mg 5 mL

2 mg/5cc 2 mg 5 cc

0.63 mg/3 mL 0.63 mg 3 mL

1.25 mg/3mL 1.25 mg 3 mL

The following Strength units are available as a drop-down list and remain unchanged from Westat edit specs:

mg

mcg

meq

mg/mL

g, gm

GR, gr

%

MI, ml

cc

mg/mcg

mg/mg

mg/hr

meq/mI

mcg/mL

u/gm

u/MI

IU

FINISH

SCREEN LAYOUT

CallRouter

DCS: ENTER 1 TO CHECK FOR DUPLICATION.

1. Check for Dups

2. Checked, No Dups

3. Dups Found

review

ENTER 1 TO FINALIZE CASE

PROGRAMMER NOTES

2019 UPDATE: If no duplicates identified, CallRouter option 2 (Checked, No Dups) will be pre-filled.

2018 UPDATE: Add the NDC-duplicate check before the exit-validate item. If there are duplicates: (1) they will be indicated in the exit-validate screen, and (2) the “comment” field will be active. Text entered in the comment field (CRIT_COMMEN) will be displayed in the grid and made available in reports.

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