PRA Package for CY2008 Plan Benefit Package (PBP) Software and Formulary Submission

The Plan Benefit Package (PBP) and Formulary Submission for Advantage (MA) Plans and Prescription Drug Plans (PDPs)

Appendix C - CY2008 Form File Record Layout_03232007

PRA Package for CY2008 Plan Benefit Package (PBP) Software and Formulary Submission

OMB: 0938-0763

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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

3/23/2007

File Typeapplication/msword
File TitleHealth Plan Management System
AuthorLori Ann Robinson
Last Modified ByCMS
File Modified2007-05-08
File Created2007-05-08

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