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

CY 2011 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

RxCUI

NUMBER
Always Required

Tier_Level

CHAR
Always Required

Drug_Type_Label

Field Length
Maximum of
8 digits

Field Description

Sample Field Value(s)

RxNorm concept unique identifier from the active
Formulary Reference File.

210597

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

CHAR
Always Required

1

Defines the Drug Type Label 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_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.”

Quantity_Limit_Days

NUM

3

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

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

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CY 2011 Formulary File Record Layout

Field Name

Field Type

Field Length

Sometimes
Required

Field Description
limit.

Sample Field Value(s)
(e.g. 9 injections every 60 days)

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

Prior_Authorization_Type

CHAR
Always Required

Prior_Authorization_Group_Desc

CHAR
Sometimes
Required

Limited_Access_YN
Therapeutic_Category_Name
Therapeutic_Class_Name
Step_Therapy_Type

Step_Therapy_Total_Groups

CHAR
Always Required
CHAR
Always Required
CHAR
Always Required
CHAR
Always Required

NUM
Sometimes
Required

1

100

1

The maximum number that will be accepted is “999”.
Is prior authorization required for the drug?

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 Prior_Authorization_Type is 0 (No) or 3 (Part D. vs.
Part B Authorization Only), then leave this field blank.
Is access to this drug limited to certain pharmacies?

0 = No Prior Authorization
1 = Prior Authorization Applies
2 = Prior Authorization Applies to
New Starts Only
3 = Part D vs. Part B Prior
Authorization Only
Antiemetics

100

Enter the name of the category for the drug.

0 = No
1 = Yes
Analgesics

100

Enter the name of the class for the drug.

Opioid Analgesics

1

Does step therapy apply to this drug?

2

Enter the total number of step therapy drug treatment
groups in which the drug is included.

0 = No Step Therapy Applies
1 = Step Therapy Applies
2 = Step Therapy Applies to New
Starts Only
3

If response to Step_Therapy_Type = 0 (No), then leave
this field blank.
The maximum number that will be accepted is “99.”

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CY 2011 Formulary File Record Layout

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_Group_Desc = “CHF Therapy” and
Step_Therapy_Step_Value = 4 should be included in adjacent columns in the file. Likewise, the values for Step_Therapy_Group_Desc = “Angina Therapy” and
Step_Therapy_Step_Value = 1 should be included in additional adjacent columns in the file. Likewise, the values for Step_Therapy_Group_Desc = “CVD
Therapy” and Step_Therapy_Step_Value = 5 should be included in additional adjacent columns in the file.
Step_Therapy_Group_Desc
CHAR
100
Description of step therapy drug treatment group. Field
Step_Therapy_Group_Desc =
Sometimes
should be repeated in the record based upon number of
“CHF Therapy”
Step_Therapy_Group_Desc =
Required
groups declared in Step_Therapy_Total_Groups.
“Angina Therapy”
If response to Step_Therapy_Type = 0 (No), then leave
Step_Therapy_Group_Desc =
this field blank.
“CVD Therapy”
Note: For a given Rx CUI, each Group Description must
be unique.

Step_Therapy_Step_Value

NUM
Sometimes
Required

2

Note: For each Step Therapy Group Description, there
must be a Rx CUI with a Step Therapy Value equal to 1.
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_Total_Groups
AND
in the same order as Step_Therapy_Group_Desc

Step_Therapy_Step_Value = 4
(e.g. Step 4 of 6)
Step_Therapy_Step_Value = 1
(e.g. Step 1 of 3)
Step_Therapy_Step_Value = 5
(e.g. Step 5 of 5)

If response to Step_Therapy_Type = 0 (No), then leave
this field blank.
The range of valid accepted values is 1 to 99.
Note: For each Step Therapy Group Description, there
must be a Rx CUI with a Step Therapy Value equal to 1.

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 (&).

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