Add Copay Tier

Use this template to add copay tiers. Copayment tiers are fixed copayment amounts depending on the class of the medication.

To Create:

  1. In the Search for Domains results page, click the Open Blank Template link at the bottom of the page. The system opens a domain template.

  2. Use the field list below to complete the page.

  3. Click the Submit button. The system saves the domain item to the database with a status of Pending.

  4. To proceed, see PPS Data Requests Tab.

Field List Template

Fields with a red asterisk are required fields that you must complete.

Description *

Copay Tier *

 

Figure: Add Copay Tier Template

 

Screenshot of add copay tier template