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

CY 2012 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

Prior_Authorization_Group_Desc

Field
Type

Maximum
Field
Length

CHAR

100

Always
Required

PA_Criteria_Change_Indicator

CHAR

1

Always
Required

Covered_Uses

CHAR

3000

Always
Required

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 2010, 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.

Exclusion_Criteria

CHAR

2000

Describe any criteria (e.g. comorbid diseases,
laboratory data, etc.) that would result in the
exclusion of coverage for an enrollee.

2000

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

500

Enter age limitations or restrictions required for prior
authorization approval.

500

Description of prescriber attribute necessary for PA to
be considered, e.g. specialist in a field or registered
under a certain program.

100

Enter the duration for which the prior authorization
will be approved.

If
applicable
Required_Medical_Information

CHAR
If
applicable

Age_Restrictions

CHAR
If
applicable

Prescriber_Restrictions

CHAR
If
applicable

Coverage_Duration

CHAR
Always
Required

CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
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CY 2012 Prior Authorization File Record Layout
Other_Criteria

CHAR

3000

Enter any other relevant criteria.

If
applicable

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 (<), and 3) semicolon (;).
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.

CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
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