CY2010 Plan Benefit Package (PBP) Software and Formulary Submission - CMS-R-262

CY 2010 Excluded Drugs 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

NDC

CHAR
Always Required

Tier

Maximum Field
Length

Field Description

Sample
Value(s)

Field

11

11-Digit National Drug Code

00000333800

CHAR
Always Required

2

Defines the Cost Share Tier Level 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 level options available to data
entry users in the Plan Benefit Package software.

Quantity_Limit_YN

CHAR
Always Required

1

Does the drug have a quantity limit restriction?

Quantity_Limit_Amount

NUM
Sometimes Required

7

If Quantity_Limit_YN = 1 (Limits Apply), enter the
quantity limit unit amount for a given prescription or
time period. The units for this amount must be
defined by a unit of measure e.g. number of tablets,
milliliters, grams, etc.

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
0 = No Quantity Limits
1 = Quantity Limits
Apply
9

If the Quantity_Limit_YN = 0 (No Limits), leave
this field blank.
The maximum number of decimal points that will be
accepted is 5., i.e., “9.99999.”

Quantity_Limit_Days

NUM
Sometimes Required

3

The maximum number that will be accepted is
“9999.99.”
Enter the number of days associated with the
quantity limit.

60 (e.g. 9 pills every 60
days)

CY 2010 Excluded Drugs File Record Layout
Field Name

Field Type

Maximum Field
Length

Field Description

Sample
Value(s)

Field

If the Quantity_Limit_YN field is 0 (No), then leave
this field blank.

Capped_Benefit_YN
Capped_Benefit_Quantity

CHAR
Always Required
NUM
Sometimes Required

1
7

The maximum logical number that will be accepted
is “999”.
Does the drug have a capped benefit limit?
If Capped_Benefit_YN field is 1 = Yes, enter the
capped benefit limit unit amount for a given
prescription or time period. The units for this
amount may be defined by a unit measure e.g.
number of tablets, number of milliliters, number of
grams, etc.

0 = No
1 = Yes
365

If the Capped_Benefit_YN field is 0 = No, then
leave this field blank
The maximum logical number that will be accepted
is “9999.99”.
Capped_Benefit_Days

NUM Sometimes
Required

3

Enter the number of days associated with the capped
benefit limit.

365 (e.g. 365 tablets
every 365 days)

If the Capped_Benefit_YN field is 0 = No, then
leave this field blank
The maximum logical number that will be accepted
is “999”
Prior_Authorization_YN
Prior_Authorization_Criteria

CHAR
Always Required
CHAR Sometimes
Required

1
1500

Is prior authorization required for the drug?
The description of the drug’s prior authorization
criteria.
If response to Prior_Authorization_YN = 0 (No),
then leave this field blank.

1 = Yes
0 = No

CY 2010 Excluded Drugs File Record Layout
Field Name

Field Type

Maximum Field
Length

Step_Therapy_YN

CHAR
Always Required

1

Step_Therapy_Criteria

CHAR Sometimes
Required

500

Field Description

Sample
Value(s)

Does step therapy apply to this drug?

1 = Yes
0 = No

Field

The description of step therapy protocol.
If response to Step_Therapy_YN = 0 (No), then
leave this field blank.

Please Note: Certain characters are restricted from HPMS. The submitted file will be rejected if any of the following characters are
included in any field: 1) greater than sign (>), 2) less than sign (<), 3) semi-colon (;), and 4) ampersand (&).