CY2013 Plan Benefit Package (PBP) Software and Formulary Submission - CMS-R-262

CY 2013 Formulary Submission File Record Layout
Required File Format = ASCII File - Tab Delimited
Do not include a header record
Filename extension should be “.TXT”
During the initial formulary submission period the file must include all drugs in the formulary. All
records must have ADD for the Change_Type.
After the initial formulary submission period the file must include only changes.
Field Name

Field Type

Field
Length

Field Description

Sample Field
Value(s)

Change_Type

CHAR

3

Defines the type of change that is being
made to the formulary.

ADD = Add RxCUI
to formulary

During the initial formulary submission
period, all rows must be “ADD.”

DEL = Delete
RxCUI from
formulary
UPD = Change
fields in the existing
RxCUI

RxCUI

NUMBER
Always
Required

Tier_Level

CHAR

Maximum
of 8 digits

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

Always
Required

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

Drug_Type_Label

CHAR

1

Always
Required

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?

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0 = No Quantity
Limits
1 = Quantity Limits
Apply

CY 2013 Formulary Submission File Record Layout
Field Name
Quantity_Limit_A
mount

Field Type

Field
Length

Field Description

NUM

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.

Sometimes
Required

Sample Field
Value(s)
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_Da
ys

NUM

3

Sometimes
Required

Enter the number of days associated
with the quantity limit.

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

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

(e.g. 9 mls every 60
days)

The maximum number that will be
accepted is “999”.
Prior_Authorizatio
n_Type

CHAR

1

Always
Required

Is prior authorization required for the
drug?

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

Prior_Authorizatio
n_Group_Desc

CHAR

100

Sometimes
Required

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.

Antiemetics

If Prior_Authorization_Type is 0 (No) or
3 (Part D. vs. Part B Authorization
Only), then leave this field blank.
Limited_Access_Y
N

Therapeutic_Cate
gory_Name

CHAR

1

Always
Required
CHAR
Always
Required

100

Is access to this drug limited to certain
pharmacies?

0 = No

Enter the name of the category for the
drug.

Analgesics

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1 = Yes

CY 2013 Formulary Submission File Record Layout
Field Name
Therapeutic_Class
_Name

Step_Therapy_Ty
pe

Field Type

Field
Length

CHAR

100

Always
Required
CHAR

1

Field Description

Sample Field
Value(s)

Enter the name of the class for the
drug.

Opioid Analgesics

Does step therapy apply to this drug?

0 = No Step
Therapy Applies

Always
Required

1 = Step Therapy
Applies
2 = Step Therapy
Applies to New
Starts Only

Step_Therapy_Tot
al_Groups

NUM

2

Sometimes
Required

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

3

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

CHAR
Sometimes
Required

100

Description of step therapy drug
treatment group. Field should be
repeated in the record based upon
number of groups declared in
Step_Therapy_Total_Groups.

Step_Therapy_Gro
up_Desc = “CHF
Therapy”

If response to Step_Therapy_Type = 0
(No), then leave this field blank.

Step_Therapy_Gro
up_Desc = “CVD
Therapy”

Note: For a given Rx CUI, each Group
Description must be unique.
Note: For each Step Therapy Group
Description, there must be a Rx CUI
with a Step Therapy Value equal to 1.

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Step_Therapy_Gro
up_Desc = “Angina
Therapy”

CY 2013 Formulary Submission File Record Layout
Field Name
Step_Therapy_Ste
p_Value

Field Type
NUM
Sometimes
Required

Field
Length
2

Field Description

Sample Field
Value(s)

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

Step_Therapy_Ste
p_Value = 4 (e.g.
Step 4 of 6)

AND

Step_Therapy_Ste
p_Value = 5 (e.g.
Step 5 of 5)

in the same order as
Step_Therapy_Group_Desc

Step_Therapy_Ste
p_Value = 1 (e.g.
Step 1 of 3)

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

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