CMS-R-262 CY 2008 Formulary File Record Layout

Health Plan Management System

CY 2008 Formulary Submission Module Requirements

Appendix C: CY 2008 Formulary File Record Layout

Required File Format = ASCII File - Tab Delimited

Do not include a header record

Filename extension should be “.TXT”

Field Name	Field Type	Field Length	Field Description	Sample Field Value(s)
Proxy NDC	CHAR Always Required	11	11-Digit National Drug Code	00000333800
Tier_Level_Value	CHAR Always Required	2	Defines the Cost Share Tier Level Value Associated with the drug. Assumption is that the drug is assigned to only one tier value. These values are consistent with the selection of tier value options available to data entry users in the Plan Benefit Package software. If no Tier Level Value applies, enter ‘1’ as the value for this field.	1 = Tier Level 1 2 = Tier Level 2 3 = Tier Level 3 4 = Tier Level 4 5 = Tier Level 5 6 = Tier Level 6 7 = Tier Level 7 8 = Tier Level 8 9 = Tier Level 9 10 = Tier Level 10
Drug_Type_Label_Value	CHAR Always Required	1	Defines the Drug Type Label Value for the drug. Enter the label value for the Drug Type from the defined list of labels.	1 = Generic 2 = Preferred Generic 3 = Non-Preferred Generic 4 = Brand 5 = Preferred Brand 6 = Non-Preferred Brand
Quantity_Limit_Amount_YN	CHAR Always Required	1	Does the drug have a quantity limit restriction?	1 = Yes 0 = No
Quantity_Limit_Amount	NUM Sometimes Required	7	If Yes to Quantity_Limit_Amount_YN, enter the quantity limit unit amount for a given prescription or time period. The units for this amount may be defined as number of pills, number of injections, etc. If the Quantity_Limit_Amount_YN field is 0 = No, then leave this field blank The maximum logical number that will be accepted is “9999.99”.	1000.75
Quantity_Limit_Days	NUM Sometimes Required	3	Enter the number of days associated with the quantity limit. If the Quantity_Limit_Amount_YN field is 0 = No, then leave this field blank The maximum logical number that will be accepted is “999”	60 (e.g. 9 pills every 60 days) (e.g. 9 injections every 60 days)
Prior_Authorization_YN	CHAR Always Required	1	Is prior authorization required for the drug?	1 = Yes 0 = No
Prior_Authorization_Group_Desc	CHAR	100	Description of the drug’s prior authorization group as it will appear on the submitted prior authorization attachment. The group name may represent a drug category or class or may simply be the name of the drug if no other grouping structure applies. If response to Prior_Authorization_YN = 0 (No), then leave this field blank.	Antiemetics
Specialty_Pharmacy_YN	CHAR Always Required	1	Does this drug have restricted access to certain specialty pharmacies?	1 = Yes 0 = No
Therapeutic_Category_Name	CHAR Always Required	100	Enter the name of the category for the drug. Note for CY 2008 this field is required for all drugs.	Analgesics
Therapeutic_Class_Name	CHAR Always Required	100	Enter the name of the class for the drug. Note for CY 2008 this field is required for all drugs.	Opioid Analgesics
Step_Therapy_YN	CHAR Always Required	1	Does step therapy apply to this drug? The only drugs that should be marked as “Yes” are those that require additional drugs to be used first.	1 = Yes 0 = No
Step_Therapy_Type_Group_Num	NUM Sometimes Required	2	Enter the total number of step therapy drug treatment groups in which the drug is included. If response to Step_Therapy_YN = 0 (No), then leave this field blank. The maximum logical number that will be accepted is “99”.	3
The remaining two fields described below should be repeated as a group or unit in the file. For example, for a given drug used in multiple Step Therapy programs, the values for Step_Therapy_Type_Group_Desc_1 = “CHF Therapy” and Step_Therapy_Type_Group_Step_1 = 4 should be included in adjacent columns in the file. Likewise, the values for Step_Therapy_Type_Group_Desc_2 = “Angina Therapy” and Step_Therapy_Type_Group_Step_2 = 1 should be included in additional adjacent columns in the file. Likewise, the values for Step_Therapy_Type_Group_Desc_3 = “CVD Therapy” and Step_Therapy_Type_Group_Step_3 = 5 should be included in additional adjacent columns in the file.
Step_Therapy_Type_Group_Desc_X	CHAR Sometimes Required	100	Description of step therapy drug treatment group. Field should be repeated in the record based upon number of groups declared in Step_Therapy_Type_Group_Num If response to Step_Therapy_YN = 0 (No), then leave this field blank.	Step_Therapy_Type_Group_Desc_1 = “CHF Therapy” Step_Therapy_Type_Group_Desc_2 = “Angina Therapy” Step_Therapy_Type_Group_Desc_3 = “CVD Therapy”
Step_Therapy_Type_Group_Step_X	NUM Sometimes Required	2	Identifies the step number or level within the sequence for the Step Therapy Group. Field should be repeated in the record based upon the number of groups declared in Step_Therapy_Type_Group_Num AND in the same order as Step_Therapy_Type_Group_Desc_X If response to Step_Therapy_YN = 0 (No), then leave this field blank. The range of valid accepted values is 1 to 99.	Step_Therapy_Type_Group_Step_1 = 4 (e.g. Step 4 of 6) Step_Therapy_Type_Group_Step_2 = 1 (e.g. Step 1 of 3) Step_Therapy_Type_Group_Step_3 = 5 (e.g. Step 5 of 5)

HPMS CTM Team HPMS Formulary Record Layout Page 4

12/21/2006