CY2011 Plan Benefit Package (PBP) Software and Formulary Submission - CMS-R-262

CY 2011 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 Field Value(s)

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.

1 = Tier Level 1
2 = Tier Level 2
3 = Tier Level 3
4 = Tier Level 4
5 = Tier Level 5
6 = Tier Level 6

Quantity_Limit_YN

CHAR
Always Required

1

Does the drug have a quantity limit restriction?

0 = No Quantity Limits
1 = Quantity Limits Apply

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.

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”.
The maximum number that will be accepted is “9999.99”.
Quantity_Limit_Days

NUM
Sometimes
Required

3

Enter the number of days associated with the quantity limit.
If the Quantity_Limit_YN field is 0 (No), then leave this field
blank.
The maximum logical number that will be accepted is “999”.

CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING

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

CY 2011 Excluded Drugs File Record Layout
Field Name

Field Type

Capped_Benefit_YN

CHAR
Always Required
NUM
Sometimes
Required

Capped_Benefit_Quantity

Maximum
Field Length

Field Description

Sample Field Value(s)

1

Does the drug have a capped benefit limit?

7

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

Step_Therapy_YN

CHAR
Always Required

Step_Therapy_Criteria

CHAR
Sometimes
Required

1
1500

1

500

Is prior authorization required for the drug?

1 = Yes
0 = No

The description of the drug’s prior authorization criteria.
If response to Prior_Authorization_YN = 0 (No), then leave this
field blank.
Does step therapy apply to this drug?

1 = Yes
0 = No

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 (&).

CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING