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

Appendix C - CY 2010 Prior Authorization 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

Prior_Authorization_Group_Desc

CHAR
Always
Required
CHAR
Always
Required

100

CHAR
Always
Required

3000

PA_Criteria_Change_Indicator

Covered_Uses

Field Length

1

Field Description
Description of the prior authorization group as it appears on the submitted
formulary file. This field must exactly match the value entered in the
Prior_Authorization_Group_Desc field on the Formulary File.
If the PA criteria content did not change for this group description compared to
CY 2009, please place a “0” in this field. If this group description is new, or the
criteria content changed in any way (e.g. additional restrictions), please place a
“1” in this field”.
Enter both the FDA-approved and off-label indications for which the drug(s) will
be covered.
At a minimum, you must enter the following in this field: “All FDA-approved
indications not otherwise excluded from Part D.”
You may enter the statement “All medically accepted indications not otherwise
excluded from Part D” if the PA will be approved for all non-excluded off-label
uses in addition to the labeled indications.
If only certain off-label uses will be approved by prior authorization, you should
list the specific uses following the “All FDA-approved indications not otherwise
excluded from Part D” statement.
Describe any criteria (e.g. comorbid diseases, laboratory data, etc.) that would
result in the exclusion of coverage for an enrollee.

Exclusion_Criteria

CHAR
If applicable

2000

Required_Medical_Information

CHAR
If applicable

2000

Enter laboratory, diagnostic, or other medical information required for initiation or
continuation of the drug(s).

Age_Restrictions

CHAR
If applicable

500

Enter age limitations or restrictions required for prior authorization approval.

Appendix C - CY 2010 Prior Authorization File Record Layout

Field Name

Field Type

Field Length

Prescriber_Restrictions

CHAR
If applicable
CHAR
Always
Required
CHAR
If applicable

500

Coverage_Duration

Other_Criteria

Field Description

100

Description of prescriber attribute necessary for PA to be considered, e.g.
specialist in a field or registered under a certain program.
Enter the duration for which the prior authorization will be approved.

3000

Enter any other relevant criteria.

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 (&).
Please Note: If the Formulary File contains only PA Type 3 or PA Type 3 and 0, then the user must upload a dummy file. This
dummy file should include only one space.