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pdfDEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
Office of Beneficiary Information Services
7500 Security Boulevard, Mail Stop S1-01-26
Baltimore, Maryland 21244-1850
OFFICE OF BENEFICIARY INFORMATION SERVICES
Date:
November 20, 2007
To:
All Medicare Part D Plans
From:
Timothy Walsh
Director, Website Project Management Group
Subject:
2008 Plan Year Pricing Data Requirements
The information on the following pages contain the updated 2008 CMS guidance and schedule for the submission of the pricing and pharmacy data
for posting on the Medicare Prescription Drug Plan Finder on www.medicare.gov.
This information will also available in the Formulary Guidance section of www.cms.hhs.gov
(http://www.cms.hhs.gov/PrescriptionDrugCovContra/03_RxContracting_FormularyGuidance.asp).
Updates to 2008 Plan Year Guidance include the following:
• Please refer to the 2008 Plan Year data submission calendar for updates to the formulary submission/approval periods.
• The Excluded Drug Formulary File (EFF) is an optional Plan Finder file submitted by Part D Sponsors for those enhanced
alternative plans which have elected to provide a supplement benefit. OTCs are not included as part of an enhanced alternative
plans supplemental benefit and therefore should not be included in EFFs. OTCs can only be covered by a plan under the plans’
administrative costs and only if those OTCs are part of that plan’s drug utilization management program.
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Common FAQs Related to the Submission of Pricing Data Files:
1. How do I get access to the Administrative Console?
Plans that are new for the 2008 plan year will receive their unique log in ID and password before the data submission that begins on Monday,
September 24, 2007. This information will be emailed to the Part D Price File Contacts listed in HPMS.
Plans that are active for the 2007 plan year will continue to use the log in ID and password that was assigned for the 2007 plan year.
2. How will CMS distinguish between the 2007 and 2008 pricing data files?
During the overlap period where both 2007 and 2008 pricing data will be submitted, CMS will distinguish the different files based on the
submission dates. 2007 pricing data will continue to be submitted on Mondays and Tuesdays and 2008 pricing data will be submitted on
Fridays per the submission calendar. Please note that the submission day for 2008 will change to Mondays and Tuesdays effective with the
data submission that begins on Monday, September 24, 2007.
3. What data needs to be submitted by plans with each of the test data submissions?
Plans will need to submit complete data files. This includes complete Pricing Files and Pharmacy Cost Files and if applicable a Reference
Pricing File and a Formulary File for Excluded Drugs.
Reference Pricing files are only to be submitted by plans using reference pricing and indicated as such in the PBP.
Formulary Files for Excluded Drugs are only to be submitted by Enhanced Alternative plans that cover excluded drugs. These plans must
also submit corresponding pricing data for these drugs in their Pricing Files.
4. Do employer (retiree) and PACE plans need to submit pricing data files.
No.
Questions about the information presented in this document should be directed to [email protected], [email protected], and
[email protected].
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2008 Plan Year Data Requirements and Submission Guidelines for the
Medicare Prescription Drug Plan Finder on www.medicare.gov
Revised Date: November 20, 2007
Objective:
The following pages contain guidance to Medicare prescription drug plans regarding additional data submission requirements for the Medicare
Prescription Drug Plan Finder that is housed on www.medicare.gov. Both stand alone prescription drug plans (PDPs) and Medicare Advantage
Prescription Drug (MA-PDs) plans will be required to submit these data to CMS and these data will be posted on www.medicare.gov. The purpose
of the data is to enable people with Medicare to compare, learn, select and enroll in a plan that best meets their needs. The database structure
provides the necessary drug pricing and pharmacy network information to accurately communicate plan information in a comparative format.
Questions regarding the data requirements outlined in this document should be directed to [email protected],
[email protected], and [email protected].
Timeline for 2008 Plan Year Data Submissions:
The initial public release of the pricing data on www.medicare.gov is tentatively scheduled for October 11, 2007. These data submissions are
required for all PDP and MAPD plans. The initial 2008 plan year data submissions will be on Fridays and will revert to the regular Monday Tuesday submission schedule effective September 24-25, 2007. **Please note that active 2007 Plan Year PDPs and MAPDs must continue
submitting their pricing and pharmacy network data on the previously released bi-weekly schedule in addition to the 2008 Plan Year data
submissions described below.
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June 15, 2007 - PDP/MAPD plans submit initial 2008 Plan Year pricing and pharmacy network data (full data set)
electronically to CMS.
June 16 – July 5, 2007 - CMS to analyze 2008 Plan Year pricing and pharmacy network data submitted by prospective plans.
July 6, 2007 - CMS to send 2008 Plan Year pricing and pharmacy network data analysis to all prospective plans.
July 13, 2007 - PDP/MAPD plans submit corrected 2008 Plan Year pricing and pharmacy network data to CMS
July 14 – August 2, 2007 - CMS to analyze “corrected” Plan Year pricing and pharmacy network data and notify plans of any
additional error/issues (if applicable)
August 9-10, 2007 - PDP/MAPD plans submit corrected 2008 Plan Year pricing and pharmacy network data to CMS
August 23-24, 2007 - PDP/MAPD plans submit corrected 2008 Plan Year pricing and pharmacy network data to CMS
September 6-7, 2007 - Plans submit 2008 Plan Year pricing and pharmacy network to CMS for final testing (Not for public
reporting)
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Date TBD – Data preview of 2008 Plan Year Pricing Data for plans.
September 10-11, 2007 – Final 2007 Plan Year pricing and pharmacy network data submission. This data will be posted
September 24, 2007 on www.medicare.gov.
September 24-25, 2007 - PDP and MAPD plans submit 2008 Plan Year pricing and pharmacy network data to CMS that will
be published on www.Medicare.gov **This data will be publicly released on www.medicare.gov on or about October 11, 2007
October 11, 2007 (tentative) – Launch of the 2008 Plan Year pricing and pharmacy network data in the Medicare Prescription
Drug Plan Finder Tool on www.medicare.gov.
Table of Contents for Sample Data File Layouts and Questions:
2008 Plan Year Data Requirements and Submission Guidelines for the Medicare Prescription Drug Plan Finder on
www.medicare.gov ............................................................................................................................................................... 3
DATA VALIDATION.............................................................................................................................................................. 5
SUBMISSION INSTRUCTIONS ........................................................................................................................................... 5
PHARMACY COST .............................................................................................................................................................. 8
PRICING FILE .....................................................................................................................................................................10
REFERENCE PRICING ......................................................................................................................................................12
FORMULARY FILE (EXCLUDED DRUGS ONLY) ..............................................................................................................16
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DATA VALIDATION
All plan submissions will be reviewed by CMS and the submission vendor for both formatting and content. In the case of validation or other
submission errors, to prevent incorrect data display, pricing data from affected plans will be suppressed from display on the tool pending corrected
data submission or plan election to utilize last successful data submission.
SUBMISSION INSTRUCTIONS
In order to provide the data specified, organizations will be given access to a Plan Compare Data Administration Console. This console will allow
sponsors to submit data, certify non-submissions, view enrollment statistics, and verify submissions. CMS will not accept data submitted in any
other format (e.g. CD, Floppy Disk, Email, etc.).
Username and Password (this username and password is assigned by DestinationRx and is separate from any username or password to
access any other CMS system)
Username and Password will be per Sponsor
o Sponsor may submit files for all programs associated with Sponsor
Username and Password will initially be assigned to Sponsor by CMS
o Given to the Part D Price File Contacts, Online Enrollment Center Contacts listed in HPMS, and Medicare Coordinators listed in
HPMS.
Connectivity
Sponsor must provide the IP networks/sub-networks masks that will be used to send the files
Sponsor will be able to manage IP address and submission status review at https://enrollmentcenter.medicare.gov/AdministrativeConsole
IP address submissions or updates must be submitted by noon on the Friday preceding the start of the data load window the following
Monday.
Any connectivity issues encountered during the data submission should be immediately sent to [email protected] or 1888-203-8497 for resolution. Support is available from 8:30 AM -6:30 PM ET. Please get your submissions in early to ensure a
timely response in case of error.
Timelines
Sponsors will be required to follow the timelines discussed above for all testing, verification, and data submissions
Regularly scheduled submissions will be made on a biweekly basis, following the submission calendar contained in this document.
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Updates or certification that no updates will be made only during the submission window on every other week beginning Monday at 12:01
AM PST and ending Tuesday at 11:59 PM PST and will be processed and displayed by 12:01 AM ET on the scheduled Monday.
If multiple files are submitted the LAST file received will be considered the final submission. If the first file was good, and the last file had an
error, your submission for that day will be considered in error.
Each time a file is submitted, please review its submission status at https://enrollmentcenter.medicare.gov/AdministrativeConsole. If they are
not received and not viewable at that URL within 30 minutes of the initial submission, the files were not received successfully, and you
should contact the Plan Compare Help Desk for support. Upon each submission, the Sponsor will also receive several email confirmations
(sent to the Part D Price File contacts).
File was received
o File has been processed and results (any errors, passed, etc.)
Each file submitted to the FTP server will be verified against the file format as listed in this document.
All required files must either be validated or come from a previous submission (this is done by certifying in the Admin Console that there are
no updates to the file).
Once all required files are accounted for, several data content checks will be performed on these files. The results will be available at
https://enrollmentcenter.medicare.gov/AdministrativeConsole.
If the file validation and data contents checks result in errors, you may resubmit your files within the same submission window.
Any difficulties encountered during submission should be addressed to [email protected] or by calling 1-888-203-8497 within
the submission window so that any necessary assistance can be provided in a timely manner. The Plan Compare Help Desk is available
between the hours of 8:30 AM ET to 6:30 PM ET.
Tracking, Logging and Monitoring
All activity will be tracked, logged, and monitored, this includes but is no limited to:
o Username used for connection
o Date and Time of connection
o Duration of connection
o Number of files uploaded
o File Processing Results (Validation and Error results)
File Formats
5. All submissions will be Fixed Length files. The filename should follow the standard: ContractIDXX.txt where ContractID is the sponsor’s
CMS defined contract_id and XX is the table name abbreviation code (defined below). Example, for a sponsor with the contract_id of
H1001 submitting a pricing file, the file name would be H1001PF.txt. Only one file per table should be submitted.
A header record should be included that specifies Contract_ID, Record Count (num (9) with leading zeros) for the entire File (Format:
XXXXXXXXX), and an 8-digit Date Created (Format: CCYYMMDD) information. A footer record should be included that again specifies
Contract_ID and EOF for End of File.
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Sample Header Record
H000100000001020080715
(Where H0001 is the Contract_ID, 000000010 is the Record Count, and 20080715 is the date)
Sample Footer Record
H0001EOF
Table Abbreviation Codes:
o Pharmacy Cost
PC
o Pricing File
PF
o Reference Pricing
RP
o Enhanced Alternative Formulary File
FF
Float (12) and Currency (12) Submission Guidelines:
- Do not include the decimal point
- The format follows this structure $$$$$$$$cccc where $$$$$$$$ are the numbers to the left of the decimal point (with leading zeros)
and the cccc are the numbers to the right of the decimal point (with trailing zeros)
- Samples:
o $1.50 = 000000015000
o 10% = 000000001000
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PHARMACY COST
Light Green Fields Indicate Unique Record Identifiers
Field Name
Type(Size)
NULL
Field Description
CONTRACT_ID
Char(5)
NOT NULL
References Organization’s Contract Number assigned by
CMS
PLAN_ID
Char(3)*
NOT NULL
References PLAN_ID that this pharmacy cost file serves
assigned by CMS. Include Leading Zeroes.
SEGMENT_ID
Char(3)*
NOT NULL
Plan Segment ID only for local MA-PD plans assigned by
CMS (If applicable). Include Leading Zeroes. PDP plans
should enter 000.
PHARMACY_NUMBER
Char(12)
NOT NULL
12-digit Pharmacy Number
• 7 digit NCPDP number with 5 preceding
zeroes, or
• 10 digit NPI number with leading one and
zero
PRICE_ID
Number(3)
NOT NULL
References the Price File Grouping Number to be used at
this pharmacy.
BRAND_DISPENSING_FEE
Currency(12)
(Format:
$$$$$$$$cccc)
NOT NULL
In addition to the ingredient cost (product cost) at the
point of sale.
GENERIC_DISPENSING_FEE
Currency(12)
(Format:
$$$$$$$$cccc)
NOT NULL
In addition to the ingredient cost (product cost) at the
point of sale.
PREFERRED_STATUS
Number(1)
DEFAULT 1,
NOT NULL
Yes/No defines whether pharmacy is preferred or nonpreferred pharmacy.
Acceptable values 0 or 1 (0=No; 1=Yes)
PHARMACY_RETAIL
NUMBER(1)
DEFAULT 1,
NOT NULL
Yes/No defines whether pharmacy is to be displayed in
retail (1 month supply) search
Acceptable values 0 or 1 (0=No; 1=Yes)
PHARMACY_MAIL
NUMBER(1)
DEFAULT 0,
NOT NULL
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Yes/No defines whether pharmacy is to be displayed in
mail-order (3 month supply) search.
Field Name
Type(Size)
NULL
Field Description
Acceptable values 0 or 1 (0=No; 1=Yes)
Notes
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PHARMACY_SPECIALTY
NUMBER(1)
DEFAULT 0,
NOT NULL
Yes/No defines whether pharmacy dispenses specialty
drugs.
PHARMACY_HI
NUMBER(1)
DEFAULT 0,
NOT NULL
Yes/No defines whether pharmacy dispenses home
infusion drugs.
PHARMACY_LTC
NUMBER(1)
DEFAULT 0,
NOT NULL
Yes/No defines whether pharmacy is considered a Long
Term Care pharmacy.
There should only be one record per pharmacy per plan. If multiple records are entered, subsequent records are ignored.
Only one PRICE_ID can be referenced per pharmacy per plan.
All PRICE_IDs listed in this file must exist in your Pricing File
PHARMACY_RETAIL and PHARMACY_MAIL are present to indicate whether a particular pharmacy offers drug sales at either a
standard one-month (retail) supply or a three-month by mail supply. Enter a 1 only for the applicable pharmacy type. If both services are
offered, you must choose one pharmacy type to identify this pharmacy. Please note, if a pharmacy offers retail 90 day supply, it is
NOT considered a mail order pharmacy, and should have a 0 for PHARMACY_MAIL.
The three fields PHARMACY_SPECIALTY, PHARMACY_HI, PHARMACY_LTC, should be used in conjunction with the retail or
mail pharmacy flags to indicate if the pharmacy dispenses drugs labeled on your formulary as being available at specialty, home infusion,
or long-term-care pharmacies only. This will allow users who have selected drugs with limited availability to choose appropriate
pharmacies for their drug baskets.
If your plan makes no distinction between network pharmacies, all network pharmacies should be treated as preferred
Submission Frequency: Organizations will be required to submit pricing on a bi-weekly basis. If no updates are required, Organizations
will be required to certify via https://enrollmentcenter.medicare.gov/AdministrativeConsole that there are no updates. In the case of no updates,
the previously submitted pricing data files will be used.
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PRICING FILE
Light Green Fields Indicate Unique Record Identifiers
Field Name
Type(Size)
NULL
Field Description
CONTRACT_ID
Char(5)
NOT NULL
References Organization’s Contract Number assigned by CMS
PRICE_ID
Number(3)
NOT NULL
Price File Grouping Number
NDC
Char(11)
NOT NULL
The appropriate 11 Digit NDC from the approved formulary
representing the drug/dosage combination
UNIT_COST
Currency(12)
(Format:
$$$$$$$$cccc)
NOT NULL
Unit cost for given NDC less dispensing fee for one-month
supply. If N/A enter 000000000000
UNIT_COST_90
Currency(12)
(Format:
$$$$$$$$cccc)
NOT NULL
Unit cost for given NDC less dispensing fee for 3-month supply.
If N/A enter 000000000000
Submission Notes: For pricing display, the tool will display one cost for all NDCs of a given drug/dosage combination. Organizations will
submit records as described above with unit costs for the specific NDCs listed in the Reference NDC List
(http://www.cms.hhs.gov/PrescriptionDrugCovContra/Downloads/CY08FRFfiles.zip) that match your plan’s CMS approved formulary.
Submission of NDCs not on the Reference NDC list will result in incorrect pricing for that drug dose combination on the drug plan finder.
For formulary drugs and generics, organizations will submit unit cost pricing as described above. Organizations must submit unit costs for all
drugs on their CMS approved formulary. Enhanced alternative plans covering excluded drugs should include the pricing for those drugs in this
file. If no pricing is submitted for a specific drug dose combination, the cost information on www.medicare.gov will be AWP minus 10% for
brand drugs and AWP minus 30% for generic drugs plus a standard dispensing fee.
Notes:
•
This file determines the base unit cost of an NDC in a given pricing regime.
•
Price_ID is identified by the Organization, within the following parameters;
o The lowest available PRICE_ID is 100
o PRICE_IDs should be assigned sequentially
o PRICE_IDs for Retail pharmacies should be between 100 and 199
o PRICE_IDs for Mail-Order pharmacies should be between 200 and 299
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o In the event that an organization has over 100 PRICE_IDs for a given type (retail or mail-order), additional PRICE_IDs should begin
sequentially in the next group of 100s where retail pharmacies are in the 300, 500, 700, 900 series, and mail-order pharmacies are in
the 400,600,800 series.
There can be multiple pricing files per organization.
The pricing file is applied to the plan through the Pharmacy Cost file.
Every drug from the formulary should be covered under each PRICE_ID. Exceptions are:
o Formulary drugs available only at specialty pharmacy may be limited to PRICE_IDs used by specialty pharmacies.
o PRICE_IDs used only for specialty pharmacies should only contain records for drugs available at pharmacies using that PRICE_ID.
Unit pricing can be provided for both a month retail supply and three-month mail-order supply. If only one type applies, enter
00000000000 in the non-applicable field. If both types apply, but are the same, enter the same value in both fields.
In order to accurately account for pricing of Part D covered vaccines, e.g., Varicella and Gardisil. For cases that apply to Vaccine
Administration only, organizations should include ingredient cost + the vaccine administration fee in the unit_cost field that is contained
in the PF. The unit cost field should be the ingredient cost per unit + the administration fee per unit.
Submission Frequency: Organizations will be required to submit pricing on a bi-weekly basis. If no updates are required, Organizations
will be required to certify via https://enrollmentcenter.medicare.gov/AdministrativeConsole that there are no updates. In the case of no
updates, the previously submitted pricing data files will be used.
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REFERENCE PRICING
Light Green Fields Indicate Unique Record Identifiers
Type(Size)
Field Name
Field Description
CONTRACT_ID
Char(5)
NOT NULL
References Organization’s Contract Number assigned
by CMS
PLAN_ID
Char(3)*
NOT NULL
References PLAN_ID that this pharmacy cost file
serves assigned by CMS
SEGMENT_ID
Char(3)*
NOT NULL
Plan Segment ID only for local MA-PD plans assigned
by CMS (If applicable)
NDC
Char(11)
NOT NULL
11-digit NDC of the drug for which reference pricing
should apply
NDC_REFERENCE
Char(11)
NOT NULL
11-digit NDC of the drug whose price and cost should
be referenced
REFERENCE_TYPE
Number(1)
NOT NULL
1=dollars and cents; 2 = percentage
Float(12)
NOT NULL
12 character number including leading zeros
REFERENCE_AMOUNT
(Format:
$$$$$$$$cccc)
If REFERENCE_TYPE=1, enter the dollar amount
with 4 implied decimal places – e.g. $15 is entered as
000000150000.
If REFERENCE_TYPE=2, enter the percentage as a
decimal value with four implied decimal places –
e.g.15% is entered as 00001500 and 100% is entered as
000000010000.
Notes
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•
•
This is an optional data file and should only be submitted by plans that are approved to offer reference pricing.
There should be one record per plan and NDC, where applicable.
The reference pricing calculation increases beneficiary’s estimated copay/co-insurance amount by applying either a fixed or percentage
fee in addition to the copay of the referenced drug.
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•
•
The reference amount can be either a fixed dollar amount OR a percentage of the difference of the total drug cost of the original and
reference drugs. For example, with a reference fee of 100%, beneficiary’s copay would be $25 if a brand drug priced at $40 is selected
over a direct generic priced at $20 with a $5 copay (i.e., $40 brand cost - $20 generic cost + the $5 copay for the generic medication).
All NDCs included in your submitted Reference Pricing file MUST match the NDCs listed on the Formulary Reference NDC List.
Submission Frequency: Organizations will be required to submit pricing on a bi-weekly basis. If no updates are required, Organizations
will be required to certify via https://enrollmentcenter.medicare.gov/AdministrativeConsole that there are no updates. In the case of no
updates, the previously submitted pricing data files will be used.
Additional Guidance on Reference File Submissions:
EXAMPLES
Assume the following information for the examples below:
Drug name
NDC
Unit price
Quantity
Dispensing fee
Monthly cost
Cost share below the Initial
Coverage Limit
BRAND_A
99123456789
$1.20
30
$2.00
$38.00
GENERIC
66987654321
$0.75
30
$2.50
$25.00
BRAND_B
55192837465
$1.50
30
$2.00
$47.00
25%
$3.00
25%
SITUATIONS THAT CAN BE HANDLED BY THE REFERENCE PRICING FILE
CASE 1: If the beneficiary chooses BRAND_A over GENERIC, he or she must pay the co-pay for the generic plus an additional $7.50 per scrip:
H0001|000000001|20060302
H0001|001|000|99123456789|66987654321|1|000000075000
H0001EOF
[NOTE: Pipes are inserted only to provide visual clarity!]
CASE 2: If the beneficiary chooses BRAND_A over GENERIC, he or she must pay the co-pay for the generic plus an additional amount equal to
the difference in the monthly cost:
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H0001|000000001|20060302
H0001|001|000|99123456789|66987654321|2|000000010000
H0001EOF
[NOTE: Pipes are inserted only to provide visual clarity!]
CASE 3: If the beneficiary chooses either BRAND_A or BRAND_B over GENERIC, he or she must pay the co-pay for the generic plus an
additional amount equal to the half the difference in the monthly cost
H0001|000000002|20060302
H0001|001|000|99123456789|66987654321|2|000000005000
H0001|001|000|55192837465|66987654321|2|000000005000
H0001EOF
[NOTE: Pipes are inserted only to provide visual clarity!]
CASE 4: If the beneficiary chooses BRAND_A over GENERIC, he or she must pay an additional amount equal to the half the difference in the
monthly cost. If BRAND_B is chosen over GENERIC, the additional amount is $8.
H0001|000000002|20060302
H0001|001|000|99123456789|66987654321|2|000000005000
H0001|001|000|55192837465|66987654321|1|000000080000
H0001EOF
[NOTE: Pipes are inserted only to provide visual clarity!]
SITUATIONS THAT CANNOT BE HANDLED BY THE REFERENCE PRICING FILE
CASE 5: The allowed monthly cost for the scrip, whether filled with BRAND_A, BRAND_B, or GENERIC, is determined by the lowest-priced
NDC for GENERIC. (In this case, the TARGET_NDC and REFERENCE_NDC point to the same product, which will create an exception.)
CASE 6: There is a surcharge if the scrip for GENERIC is filed from any manufacturer’s bottle except Manufacturer X. (Again, the
TARGET_NDC and REFERENCE_NDC point to the same product, which will create an exception.)
REFERENCE PRICING FILE EDIT CHECKS
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The following edit checks are applied to each file submitted to DestinationRx for the Plan Finder website. An exception is generated as the result
of any of the conditions listed below. In the text that follows, TARGET_NDC refers to the product subject to reference pricing and
REFERENCE_NDC refers to the product that forms the reference.
1. Invalid NDC
TARGET_NDC or REFERENCE_NDC is inactive or obsolete.
2. Incorrect specification of REF_TYPE
REF_TYPE is neither 1 (surcharge is in dollars) nor 2 (surcharge is in percentage terms)
3. Anomalous REF_AMT
REF_AMT=0 (no surcharge)
REF_TYPE=2 and REF_AMT>1 (surcharge exceeds 100%)
REF_TYPE=1 and REF_AMT<=1
4. Reference drug or Target drug is not on formulary
Drug product (name/form/strength) associated with REFERENCE_NDC is not found in the relevant Formulary File submitted to
DestinationRx.
5. Multiple references
The product associated with TARGET_NDC is paired with more than one other product (associated with REFERENCE_NDCs).
6. Auto-referencing
TARGET_NDC and REFERENCE_NDC are associated with the same product (name/form/strength).
7. Looping reference pricing
TARGET_NDC is associated with a product that is also associated with REFERENCE_NDC elsewhere in the Reference Pricing file (i.e.,
Product A is referenced to Product B, which in turn is referenced to Product C)
8. Reverse reference pricing
REF_TYPE = 2 and TARGET_NDC is a LOWER cost product than REFERENCE_NDC.
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FORMULARY FILE (EXCLUDED DRUGS ONLY; THIS FILE WILL ONLY BE ACCEPTED FROM
ENHANCED ALTERNATIVE PLANS COVERING EXCLUDED DRUGS)
Light Green Fields Indicate Unique Record Identifiers
Field Name
Type(Size)
NULL
Field Description
CONTRACT_ID
Char(5)
NOT NULL
References Organization’s Contract Number assigned
by CMS
FORMULARY_ID
Number(8)
NOT NULL
Unique Identifier
NDC
Char(11)
NOT NULL
11 digit (include leading zeros)
TIER_LEVEL_VALUE
Number(2)
NOT NULL
Defines the Cost Share Tier Level Value Associated
with the NDC. Assumption is that the NDC is
assigned to one tier value. These values are consistent
with the selection of 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.
FORMULARY_VERSION
Number(5)
NOT NULL
Unique version ID assigned to this formulary. The
version # will be incremented by one for each new
submission. This will be synchronized with the HPMS
formulary
QUANTITY_LIMIT_AMOUNT_YN
Number(1)
DEFAULT 0,
NULL
Does the NDC have a quantity limit other than a 30day or 34-day limit?
Acceptable values 0 or 1 (0=No; 1=Yes)
PRIOR_AUTHORIZATION_YN
Number(1)
DEFAULT 0,
NOT NULL
Is prior authorization required for the NDC?
Acceptable values 0 or 1 (0=No; 1=Yes)
STEP_THERAPY_YN
Number(1)
DEFAULT 0,
NOT NULL
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.
Step one level drugs in a step therapy algorithm should
be marked “No”.
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Field Name
Type(Size)
NULL
Field Description
Acceptable values 0 or 1 (0=No; 1=Yes)
SPECIALTY_YN
Number(1)
DEFAULT 0,
NOT NULL
Is this drug available only at specialty pharmacies?
Acceptable values 0 or 1 (0=No; 1=Yes)
Notes:
•
•
•
•
•
•
•
•
•
This file CAN ONLY be submitted for enhanced alternative plans that cover all or some excluded drugs. The CMS approved
formulary in HPMS will be used to display all other formulary drugs.
This file will provide the tier information by NDC for excluded drugs.
Drugs included on the plan’s CMS approved formulary in HPMS CANNOT be included in this file.
A formulary file will be assigned to plans for the organization via the formulary_id.
Enhanced Alternative plans not submitting excluded drug formulary files will be assumed to not cover excluded drugs
As the plan selector application is primarily designed to provide beneficiaries with information to select a drug plan that meets their needs
and not a tool for current drug plan enrollees to seek information about their plan, this tool will disregard the 60-day notice window
required when a drug changes tiers. Thus, a tier will display in its new tier prior to the expiration of the 60-day notice window. Plans are
required to notify all current plan enrollees about any formulary changes before the changes are implemented.
Organizations will submit the formulary as described above for all covered excluded drug NDCs in the plan’s formulary. Fields available
in HPMS will be subject to Data Validation described above.
An NDC can only exist in one tier per formulary.
OTCs are not included as part of an enhanced alternative plans supplemental benefit and therefore should not be included in EFFs. OTCs
can only be covered by a plan under the plans’ administrative costs and only if those OTCs are part of that plan’s drug utilization
management program.
Submission Frequency: Organizations will be required to submit pricing on a bi-weekly basis. If no updates are required, Organizations
will be required to certify via https://enrollmentcenter.medicare.gov/AdministrativeConsole that there are no updates. In the case of no
updates, the previously submitted pricing data files will be used.
17
2008 Plan Year Pricing Data Submission Calendar
Key:
Color Key
Scheduled data posting date on the Medicare Prescription Drug
Plan Finder
Scheduled 2007 Plan Year Data Submission dates.
Monthly Formulary Submission Window
Monthly Formulary Approval Date
Scheduled 2008 Plan Year Data Submission dates
Initial Release of 2008 Plan Year Data
Final Data Submission for the 2007 Plan Year
18
May 2007
Sun
Mon
Tue
Wed
Thu
1
Formulary
Submission
Window
6
2
Fri
Sat
3
4
5
9
10
11
12
16
17
18
19
23
24
25
26
Formulary
Submission
Window
Formulary
Submission
Window
Submit Pricing
7 Data
8
4/24 Pricing
Data Posted on
the Drug Plan
Finder
Mother's Day
13
14
15
Approval
Deadline for
May Formulary
Submission
20
Submit Pricing
21 Data
22
5/8 Pricing Data
Posted on the
Drug Plan
Finder
Memorial Day
27
28
Online
Analysis Tool
Training
during the Biweekly User
Group Call
29
30
CalendarsThatWork.com
19
31
June 2007
Sun
Mon
Tue
Wed
Thu
Fri
Sat
1
2
Formulary
Submission
Window
3
Submit Pricing
Data
4
5/22 Pricing Data
Posted on the Drug
Plan Finder
Formulary
Submission
Window
10
11
Father's Day 17
Submit Pricing
Data
18
Submit Pricing
Data
5
Formulary
Submission
Window
12
Submit Pricing
Data
19
6
7
8
9
13
14
15
Initial 2008 Plan
Year Pricing Test
Data Submission
– this data will not
be publicly
released
16
20
21
22
23
27
28
29
30
6/5 Pricing Data
Posted on the Drug
Plan Finder
24
25
Approval Deadline
for June
Formulary
Submission
26
CalendarsThatWork.com
20
July 2007
Sun
Mon
1
Tue
Submit Pricing
Data
2
6/19 Pricing Data
Posted on the Drug
Plan Finder
Formulary
Submission
Window
8
9
15
Submit Pricing
Data
16
Wed
Submit Pricing
Data
3
Formulary
Submission
Window
Thu
Independence Day
4
Formulary
Submission
Window
10
Submit Pricing
Data
17
Fri
Sat
5
6
7
11
12
13
2nd 2008 Plan Year
Pricing Test Data
Submission – this
data will not be
publicly released
14
18
19
20
21
25
26
27
28
Formulary
Submission
Window
7/3 Pricing Data
Posted on the Drug
Plan Finder
22
29
23
Approval Deadline
for July Formulary
Submission
Submit Pricing
Data
30
24
Submit Pricing
Data
31
7/17 Pricing Data
Posted on the Drug
Plan Finder
CalendarsThatWork.com
21
August 2007
Sun
Mon
Tue
Wed
Thu
1
Formulary
Submission
Window
Fri
2
Sat
3
4
Formulary
Submission
Window
Formulary
Submission
Window
5
6
7
8
9
3rd 2008 Plan Year
Pricing Test Data
Submission – this
data will not be
publicly released
10
3rd 2008 Plan Year
Pricing Test Data
Submission
11
12
Submit Pricing
Data
13
Submit Pricing
Data
14
15
16
17
18
21
22
23
4th 2008 Plan Year
Pricing Test Data
Submission – this
data will not be
publicly released
24
4th 2008 Plan Year
Pricing Test Data
Submission
25
Submit Pricing
Data
28
29
30
31
7/31 Pricing Data
Posted on the Drug
Plan Finder
19
26
20
Approval Deadline
for August
Formulary
Submission
Submit Pricing
Data
27
8/14 Pricing Data
Posted on the Drug
Plan Finder
CalendarsThatWork.com
22
September 2007
Sun
Mon
Tue
Wed
Thu
Fri
Sat
1
2
Labor Day 3
4
Formulary
Submission
Window
9
5
6
5th 2008 Plan Year
Pricing Test Data
Submission – this
data will not be
publicly released
Formulary
Submission
Window
7
5th 2008 Plan Year
Pricing Test Data
Submission
8
12
Rosh Hashanah 13
Rosh Hashanah 14
15
Formulary
Submission
Window
Submit Pricing
Data
10
8/28 Pricing Data
Posted on the Drug
Plan Finder
Final 2007 Plan
Year Pricing Data
Submission
Submit Pricing Data
11
Final 2007 Plan
Year Pricing Data
Submission
17
18
19
20
21
Yom Kippur 22
24
25
26
27
28
29
16
Approval
Deadline for
September
Formulary
Submission
23
Initial 2008 Plan
Year Data to be
Released 10/11 –
9/11 Pricing Data
Posted on the Drug
Plan Finder
Initial 2008 Plan
Year Data to be
Released 10/11
30
23
October 2007
Sun
Mon
Tue
1
Formulary
Submission
Window
Wed
2
Thu
Fri
Sat
3
4
5
6
9
10
11
Tentative Date
for the Release
of 2008 Plan
Year Data
12
13
16
17
18
19
20
23
24
25
26
27
30
31
Formulary
Submission
Window
Formulary
Submission
Window
Columbus Day
7
8
Submit 2008
Plan Year
Pricing Data
14
Submit 2008
Plan Year
Pricing Data
15
Submit 2008
Plan Year
21 Pricing Data 22
10/9 Pricing
Data Posted on
the Drug Plan
Finder
28
29
Submit 2008
Plan Year
Pricing Data
Approval Deadline
for October
Formulary
Submission
CalendarsThatWork.com
24
November 2007
Sun
Mon
Tue
Submit 2008
Plan Year
4 Pricing Data 5
10/23 Pricing
Data Posted on
the Drug Plan
Finder
Veterans' Day
11
12
Submit 2008
Plan Year
18 Pricing Data 19
11/6 Pricing
Data Posted on
the Drug Plan
Finder
25
26
Wed
Thu
Fri
Sat
1
2
3
6
7
8
9
10
13
14
15
2008 Plan Year
Annual
Enrollment
Period Begins
16
17
20
Thanksgiving
21 Day
22
23
24
27
28
30
Submit 2008
Plan Year
Pricing Data
Submit 2008
Plan Year
Pricing Data
CalendarsThatWork.com
25
29
December 2007
Sun
Mon
Tue
Wed
Thu
Fri
Sat
1
Submit 2008 Plan
2 Year Pricing Data 3
11/20 Pricing Data
Posted on the Drug
Plan Finder
Formulary
Submission
Window
9
4
6
7
8
11
12
13
14
15
18
19
20
21
22
25
26
27
28
29
Formulary
Submission
Window
10
Submit 2008
Plan Year
16 Pricing Data 17
12/4 Pricing
Data Posted on
the Drug Plan
Finder
23
24
5
Submit 2008 Plan
Year Pricing Data
Formulary
Submission
Window
Submit 2008
Plan Year
Pricing Data
Christmas
Approval Deadline
for December
Formulary
Submission
30 New Year's Eve 31
Submit 2008
Plan Year
Pricing Data
2/18 Pricing
Data Posted on
the Drug Plan
Finder
26
January 2008
Sun
Mon
Tue
Wed
New Year's Day 1
Submit 2008
Plan Year
Pricing Data
6
Thu
2
Formulary
Submission
Window
Fri
3
Formulary
Submission
Window
Sat
4
5
Formulary
Submission
Window
7
8
9
10
11
12
Submit Pricing
13 Data
14
1/1 Pricing Data
Posted on the
Drug Plan
Finder
Submit Pricing
Data
15
16
17
18
19
20
22
Approval
Deadline for
January
Formulary
Submission
Submit Pricing
Data
29
23
24
25
26
30
31
21
Martin Luther
King Day
Submit Pricing
27 Data
28
1/15 Pricing
Data Posted on
the Drug Plan
Finder
CalendarsThatWork.com
27
February 2008
Sun
Mon
Tue
Wed
Thu
Fri
Sat
1
2
Formulary
Submission
Window
3
4
Formulary
Submission
Window
Submit Pricing
10 Data
11
1/29 Pricing
Data Posted on
the Drug Plan
Finder
17
President's Day
18
Submit Pricing
24 Data
25
2/12 Pricing
Data Posted on
the Drug Plan
Finder
5
6
7
8
9
Submit Pricing
Data
12
13
14
15
16
20
21
22
23
27
28
29
Formulary
Submission
Window
19
Approval
Deadline for
February
Formulary
Submission
Submit Pricing
Data
26
CalendarsThatWork.com
28
March 2008
Sun
Mon
Tue
Wed
Thu
Fri
Sat
1
2
3
Formulary
Submission
Window
4
Formulary
Submission
Window
5
6
7
8
12
13
14
15
19
20
Good Friday 21
22
26
27
28
29
Formulary
Submission
Window
Submit Pricing
Submit Pricing
9 Data
10 Data
11
2/26 Pricing
Data Posted on
the Drug Plan
Finder
16
17
18
Approval
Deadline for
March
Formulary
Submission
Submit Pricing
Submit Pricing
Easter 23 Data
24 Data
25
3/11 Pricing
Data Posted on
the Drug Plan
Finder
30
31
CalendarsThatWork.com
29
April 2008
Sun
Mon
Tue
Wed
1
Formulary
Submission
Window
Submit Pricing
6 Data
7
Thu
2
Formulary
Submission
Window
Fri
Sat
3
4
5
Formulary
Submission
Window
Submit Pricing
Data
8
9
10
11
12
14
15
16
17
18
19
Submit Pricing
20 Data
21
Approval
Deadline for
April
Formulary
Submission
Submit Pricing
Data
22
23
24
25
26
29
30
3/25 Pricing
Data Posted on
the Drug Plan
Finder
13
Passover
Begins
4/8 Pricing Data
Posted on the
Drug Plan
Finder
27
28
CalendarsThatWork.com
30
May 2008
Sun
Mon
Tue
Wed
Thu
Fri
1
Formulary
Submission
Window
Submit Pricing
4 Data
5
Sat
2
3
Formulary
Submission
Window
Submit Pricing
Data
6
7
8
9
10
12
13
14
15
16
17
Submit Pricing
18 Data
19
Submit Pricing
Data
20
21
22
23
24
28
29
30
31
4/22 Pricing
Data Posted on
the Drug Plan
Finder
Formulary
Submission
Window
11
Mother's Day
5/6 Pricing Data
Posted on the
Drug Plan
Finder
Memorial Day
25
26
27
Approval
Deadline for
May Formulary
Submission
CalendarsThatWork.com
31
June 2008
Sun
Mon
Tue
Submit Pricing
2
1 Data
5/20 Pricing
Data Posted on
the Drug Plan
Finder
Formulary
Submission
Window
8
Wed
Submit Pricing
Data
3
Formulary
Submission
Window
Thu
Fri
Sat
4
5
6
7
Formulary
Submission
Window
9
10
11
12
13
14
Submit Pricing
15 Data
16
Submit Pricing
Data
17
18
19
20
21
24
25
26
27
28
Father's Day
6/3 Pricing Data
Posted on the
Drug Plan
Finder
22
23
Approval
Deadline for
June
Formulary
Submission
Submit Pricing
29 Data
30
6/17 Pricing
Data Posted on
the Drug Plan
Finder
CalendarsThatWork.com
32
July 2008
Sun
Mon
Tue
Wed
Submit Pricing
Data
1
Formulary
Submission
Window
6
Thu
2
Formulary
Submission
Window
Fri
Sat
3
4
5
Independence
Day
Formulary
Submission
Window
7
8
9
10
11
12
Submit Pricing
13 Data
14
Submit Pricing
Data
15
16
17
18
19
23
24
25
26
30
31
7/1 Pricing Data
Posted on the
Drug Plan
Finder
20
21
22
Approval
Deadline for
July Formulary
Submission
Submit Pricing
27 Data
28
Submit Pricing
Data
29
7/15 Pricing
Data Posted on
the Drug Plan
Finder
CalendarsThatWork.com
33
August 2008
Sun
Mon
Tue
Wed
Thu
Fri
Sat
1
2
Formulary
Submission
Window
3
4
5
6
7
8
9
Submit Pricing
10 Data
11
Submit Pricing
Data
12
13
14
15
16
7/29 Pricing
Data Posted on
the Drug Plan
Finder
17
18
19
20
21
22
23
27
28
29
30
Formulary
Submission
Window
Submit Pricing
24 Data
25
8/12 Pricing
Data Posted on
the Drug Plan
Finder
Formulary
Submission
Window
Submit Pricing
Data
26
Approval
Deadline for
August
Formulary
Submission
31
CalendarsThatWork.com
34
| File Type | application/pdf |
| File Title | DEPARTMENT OF HEALTH & HUMAN SERVICES |
| Author | CMS |
| File Modified | 2008-07-09 |
| File Created | 2007-11-21 |