Form CMS-10150 2014 Pricing Data Guidelines

DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
Office of Communications
7500 Security Boulevard, Mail Stop S1-01-26
Baltimore, Maryland 21244-1850

OFFICE OF COMMUNICATIONS
Date:

April 26, 2013

To:

All Medicare Part D Plans

From:

Jon Booth
Director, Web and New Media Group

Subject:

CY2014 Pricing Data Requirements

The information on the following pages contain the updated CY 2014 CMS guidance and schedule for the submission of the pricing
and pharmacy data for posting on the Medicare Plan Finder on www.Medicare.gov.
Changes and clarifications to the requirements in this update include the following:
• PC File:
o Price_ID values from 001 through 099 are open to use. These can be used for Retail or Mail Order pharmacy data
sets.
• PF File:
o Ceiling_Price and Ceiling_Quantity fields removed. New file created for plans that offer ceiling price (see Ceiling
Price file notes below).
o Has_Ceiling field added to indicate if the NDC at that days supply and pharmacy has a ceiling price in the CP file.
• Ceiling Price (CP) File:
o New file for submissions. This is added in order to provide plans with ability to provide ceiling costs for drugs at
different quantity levels. Examples provided in Ceiling Price File note section.

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o Ceiling_Price and Ceiling_Quantity fields indicate the ceiling price and quantity for a specific NDC. Ceiling
pricing reflects an agreement between a plan sponsor and a pharmacy to charge a specific amount for a defined list
of medications at a defined fill quantity. The ceiling price is set below the standard plan copay for those
medications in order to provide an additional cost savings for the beneficiary.
o Only Plans offering Ceiling Pricing are required to submit Ceiling Pricing (CP) files.

Common FAQs Related to the Submission of Pricing Data Files:
1. How do I get access to the Administrative Console?
Plans that are new for CY2014 will receive their unique log in ID and password before the initial test data submission. This
information will be emailed to the Part D Price File Contacts listed in HPMS. Plans that are active for the CY2013 will
continue to use the log in ID and password that was assigned for CY2013. Please contact the Plan Compare Help Desk if you
are missing login credentials for a Contract ID (see Question 5 for contact information).
2. How will CMS distinguish between the CY2013 and CY2014 pricing data files?
During the overlap period where both CY 2013 and CY 2014 pricing data will be submitted, CMS will distinguish the different
files based on the submission dates. CY2013 pricing data will continue to be submitted on Mondays and Tuesdays and CY
2014 test pricing data will be submitted on Thursdays and Fridays per the submission calendar. Please note that the submission
day for CY 2014 will change to Mondays and Tuesdays effective with the data submission that begins on Monday, September
9, 2013.
In addition, plans should follow the standards as specified for the header record for each Part D data file (Contract ID, CY,
Record Count, and Date Created). Please refer to the File Formats section for details.
3. What data needs to be submitted by plans with each of the test data submissions?
Plans will need to submit complete data files. This includes complete Pharmacy Cost (PC) and Pricing File (PF) files.

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4. Which data will be used for the CY 2014 posting on www.Medicare.gov?
Data submitted by sponsors on September 9 – 10, 2013 will be posted on www.Medicare.gov on or about October 1st, 2013.
Please note that previously submitted test data will not be used for posting on www.Medicare.gov.
5. How do I get in contact with the technical helpdesk?
Plans can email [email protected] or call (888) 203-8497 between the hours of 8:30AM and 6:30PM ET.
Correspondence received after 6:30PM ET will be returned the following business day. To expedite assistance, plans should
provide the Contract and Plan IDs.
6. If my plan offers OTC drugs as part of supplemental benefit, should I include them to my PF file submission?
No. OTC drugs (applicable only to those plans that have indicated OTC coverage in their Part D PBP submission to CMS) are
provided to the beneficiary without any direct cost sharing at the point of sale. As such, they should not be included as part of
your PF files submission.
7. Can I submit pricing for drugs that are not included on my plan’s approved formulary?
No. In CY2014, in the PF file submissions, plans should continue to only submit pricing for drugs on the approved formulary
that are associated with a related NDC and/or NDCs from the approved excluded drug supplemental file of enhanced
alternative plans.
8. Is there a certain SFTP client application I should use to submit my Part D files?
No. There are numerous SFTP client applications currently available to plan sponsors. As SFTP is an industry standard
network protocol for file transfer, any available SFTP client application will be sufficient to CMS. Please consult with your
organization’s IT department for assistance with selection and configuration of appropriate SFTP client for your organization.
Any questions about the information presented in this document should be directed to [email protected],
[email protected], and [email protected].

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CY2014 Data Requirements and Submission Guidelines for the
Medicare Plan Finder Tool on www.Medicare.gov
Revised Date: April 26, 2013

Objective:
The following pages contain guidance to Medicare prescription drug plans regarding additional data submission requirements for the Medicare Plan
Finder that is housed on www.Medicare.gov. Both stand-alone prescription drug plans (PDPs) and Medicare Advantage Prescription Drug (MAPDs) plans will be required to submit these data to CMS and these data will be posted on www.Medicare.gov. The purpose of the data is to enable
people with Medicare to compare, learn, select and enroll in a plan that best meets their needs. The database structure provides the necessary drug
pricing and pharmacy network information to accurately communicate plan information in a comparative format.
Questions regarding the data requirements outlined in this document should be directed to [email protected], and [email protected].
**Please note that active CY2013 PDPs and MA-PDs must continue submitting their pricing and pharmacy network data as detailed in the
CY2013 Data Guidelines. The schedule below is in addition to normal CY2013 submissions. The final CY 2013 plan finder data submission
is August 19 – 20, 2013.
Timeline for CY2014 Data Submissions:
The initial public release of the pricing data on www.Medicare.gov is tentatively scheduled for October 1st, 2013. These data submissions are
required for all PDP and MA-PD plans (with the exception of Employer (retiree), PACE, and Cost plans). The initial CY2014 data submissions will
be on Thursdays and Fridays and will revert to the regular Monday - Tuesday submission schedule effective September 9 – 10, 2013.
• July 11 and 12, 2013 – PDP/MA-PD plans submit initial (Test Submission #1) CY2014 pricing and pharmacy network data (full data
set) electronically to CMS using SFTP process.
• Primary objective for this submission window will be for plans to test their SFTP application’s configuration and establish
successful connectivity and file transfer utilizing the SFTP process.
• OAT data integrity checks will be turned off for the initial submission. However, format validation checks will be turned on.
• CMS will NOT be performing the full set of quality assurance (QA) checks on these data. Instead, plans should review their
submission results directly from the Plan Compare Administrative Console.
• July 25 and 26, 2013 – PDP/MA-PD plans submit corrected (Test Submission #2) CY2014 pricing and pharmacy network data to
CMS.
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Format validation checks and OAT data integrity checks will be turned on for this Test Submission.
CMS will be performing the full set of quality assurance (QA) checks on these data and will send CY2014 pricing and
pharmacy network data analysis to plans.
• PF/FF Mismatch check will be based on Plan’s CY2014 formulary and supplemental excluded drug file (if applicable)
submitted to CMS as of July 22, 2013.
August 14 – 16, 2013 – Drug Pricing Data Preview #1 of CY2014 Pricing Data for plans. Drug Pricing Data Preview #1 will be based
on the following Test Data for CY2014: (display of test data as part of Drug Pricing Data Preview #1 should not be considered as an
indication of CMS approval).
• CY2014 pricing and pharmacy network data submitted on July 25-26, 2013 (Test Submission #2).
• Plan’s CY2014 formulary and supplemental excluded drug file (if applicable) as submitted to CMS as of July 22, 2013.
• Plan’s CY2014 plan benefit information as submitted to CMS as of August 7, 2013.
August 19 – 20, 2013 – Final regular CY2013 pricing and pharmacy network data submission. These will be the last CY2013
data submission prior to CY2014 Open Enrollment. These data will be posted on September 2, 2013 on www.Medicare.gov.
Current FTP process will be utilized for submission of files.
August 22 – 23, 2013 – Plans submit (Test Submission #3) CY2014 pricing and pharmacy network to CMS for final testing (Not for
public reporting).
• Format validation checks and OAT data integrity checks will be turned on for this Test Submission. PF/FF Mismatch check
will be based on Plan’s CY2014 formulary and supplemental excluded drug file (if applicable) submitted to CMS as of August
8, 2013.
• Plan’s CY2014 plan benefit information as submitted to CMS as of August 27, 2013.
• CMS will be performing the full set of quality assurance (QA) checks on these data and will send CY2014 pricing and
pharmacy network data analysis to plans.
September 2 – 3, 2013 – There will be no CY2013 or CY2014 pricing submissions this week.
September 4 – 6, 2013 – Drug Pricing Data Preview #2 of CY2014 Pricing Data for plans. Drug Pricing Data Preview #2 will be
based on the following Test Data for CY2014: (display of test data as part of Drug Pricing Data Preview #2 should not be considered
as an indication of CMS approval).
• CY2014 pricing and pharmacy network data submitted on August 22 – 23, 2013 (Test Submission #3).
• Plan’s CY2014 formulary and supplemental excluded drug file (if applicable) as submitted to CMS as of August 8, 2013.
• Plan’s CY2014 plan benefit information as submitted to CMS as of August 27, 2013.
September 9 – 10, 2013 – PDP and MA-PD plans submit CY2014 pricing and pharmacy network data to CMS that will be published
on www.Medicare.gov. These data will be publicly released on www.Medicare.gov on or about October 1, 2013.
September 23 – 24, 2013 – There will be no CY2013 or CY2014 pricing submissions this week.
October 1, 2013 (tentative) – Launch of the CY2014 pricing and pharmacy network data in the Medicare Plan Finder Tool on
www.Medicare.gov
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Plans cannot certify in the Administrative Console that there are no updates to files. If there are no updates to the files, the same files
should be submitted. If there are data changes, updated files must be submitted.
Table of Contents for Sample Data File Layouts and Questions:
CY2014 Data Requirements and Submission Guidelines for the Medicare Plan Finder Tool on www.Medicare.gov ......... 4
DATA VALIDATION.............................................................................................................................................................. 7
SUBMISSION INSTRUCTIONS ........................................................................................................................................... 7
PHARMACY COST .............................................................................................................................................................10
PRICING FILE .....................................................................................................................................................................13
CEILING PRICE FILE ..........................................................................................................................................................17

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DATA VALIDATION
All plan submissions will be reviewed by CMS and the submission vendor for both formatting and content. In the case of validation or other
submission errors, to prevent incorrect data display, pricing data from affected plans will be suppressed from display on the tool pending corrected
data submission or plan election to utilize last successful data submission.

SUBMISSION INSTRUCTIONS
In order to provide the data specified, organizations will be given access to a Plan Compare Data Administration Console. This console will allow
sponsors to submit data and verify submissions (including results for file format validation and data integrity checks). CMS will not accept data
submitted in any other format (e.g. CD, Floppy Disk, Email, etc.).
Username and Password (this username and password is assigned by DRX and is separate from any username or password to access any
other CMS system)

Username and Password issued to the Sponsor will be unique for each Contract_ID.

Sponsors with multiple Contracts will still be allowed to submit files for multiple Contract_IDs with single connection.

Username and Password will initially be assigned to Sponsor by DRX and given to the Part D Price File Contacts, Online Enrollment Center
Contacts, and Medicare Coordinators listed in HPMS for each Contract_ID.

Super User Accounts: A new account type was added in 2010 for users that submit pricing files for more than 1 Contract ID. The Super User
login allows a user to view the submission results of multiple Contracts. In order to set up a Super User account, the user must be listed as a
contact in HPMS for each of the Contract IDs. Contact the Plan Compare Help Desk at 888-203-8497 or [email protected], if you wish
to set one up or have any questions.
Connectivity

The Sponsor will be required to use SFTP (Secure File Transfer Protocol) client application to send the files, including both Test Submission
and Regular Submissions.

IP registration will not be required for CY2014 submissions.

General guidance on configuring and utilizing the SFTP client will be posted on Plan Compare Administrative Console.

CY2013 submissions will still be completed using the current SFTP process. All existing submission guidelines for CY2013 have not
changed and are still applicable for CY2013 submissions.

For use during test submissions for CY2014 only, sponsors will be able to review submission status at Test Submission Plan Compare
Administrative Console with the same username and password assigned to Sponsor by DRX. URL for the Test Submission Plan Compare
Administrative Console will be provided to all sponsors prior to first CY2014 Test Submission window.

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Any connectivity issues encountered during the data submission should be immediately sent to [email protected] (888-2038497) for resolution. Support is available from 8:30AM – 6:30PM ET Monday through Friday. Correspondence received after
6:30PM ET will be returned the next business day. Please get your submissions in early to ensure a timely response in case of error.

Timelines

Sponsors will be required to follow the timelines discussed above for all testing, verification, and data submissions.

Regularly scheduled submissions will be made on a biweekly basis following the submission calendar contained in this document.

Sponsors will no longer be able to auto-certify files and will be required to update files during every regular submission window.

Updates will be made only during the submission window on every other week beginning Monday 12:01AM PST and ending Tuesday
11:59PM PST and will be processed and displayed by 12:01 AM (PST) on the scheduled Monday.

If multiple files are submitted, the LAST file received will be considered the final submission. If the first file was good, and the last file had
an error, your submission for that day will be considered in error.

Each time a file is submitted, please review its submission status at https://medicareadmin.drx.com/SubmissionStatus/login.aspx.

If they are not received and not viewable at that URL within 60 minutes of the initial submission, the files were not received successfully,
and you should contact the Plan Compare Help Desk for support. Upon each submission, the Sponsor will also receive several email
confirmations (sent to the Part D Price File contacts).
o File was received
o File has been processed and results (any errors, passed, etc.)

Each file submitted by the plan will be verified against the file format as listed in this document.

All required files must be validated. Plans must upload updated files when data changes occur.

Once all required files are accounted for, several data content checks will be performed on these files. The results will be available at
https://medicareadmin.drx.com/SubmissionStatus/login.aspx.

If the file validation and data contents checks result in errors, you may resubmit your files within the same submission window.

Any difficulties encountered during submission should be addressed to [email protected] within the submission window so that any
necessary assistance can be provided in a timely manner. The Plan Compare Help Desk (at 888-203-8497) is available between the hours of
8:30AM – 6:30PM ET.
Tracking, Logging and Monitoring

All activity will be tracked, logged, and monitored. This includes, but is not limited to:
o Username used for connection
o Date and Time of connection
o Duration of connection
o Number of files uploaded
o File Processing Results (Validation and Error results)

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File Formats
1. All submissions will be Fixed Length files. The filename should follow the standard: ContractIDXX.txt where ContractID is the sponsor’s
CMS defined Contract ID# and XX is the table name abbreviation code (defined below). Example, for a sponsor with the Contract ID of
H1001 submitting a pricing file, the file name would be H1001PF.txt. Only one file per table should be submitted.
A header record should be included that specifies Contract ID, CY (Format: YYYY), Record Count (num (9) with leading zeros) for the
entire File (Format: XXXXXXXXX), and an 8-digit Date Created (Format: CCYYMMDD) information. A footer record should be included
that again specifies Contract ID and EOF for End of File.
Sample Header Record
H1001201400000001020130715
(Where H1001 is the Contract ID, 2014 is the CY, 000000010 is the Record Count, and 20130715 is the date)
Sample Footer Record
H1001EOF
Table Abbreviation Codes:
o Pharmacy Cost
o Pricing File
o Ceiling Price

PC
PF
CP

Float(12) and Currency(12) Submission Guidelines:
- Do not include the decimal point
- The format follows this structure $$$$$$$$cccc where $$$$$$$$ are the numbers to the left of the decimal point (with leading zeros)
and the cccc are the numbers to the right of the decimal point (with trailing zeros)
- Samples:
o $1.50 = 000000015000
o 10% = 000000001000

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PHARMACY COST
Light Green Fields Indicate Unique Record Identifiers
Field Name

Type(Size)

NULL

Field Description

CONTRACT_ID

Char(5)

NOT NULL

References Organization’s Contract Number assigned by
CMS

PLAN_ID

Char(3)*

NOT NULL

References PLAN_ID that this pharmacy cost file serves
assigned by CMS. Include Leading Zeros.

SEGMENT_ID

Char(3)*

NOT NULL

Plan Segment ID only for local MA-PD plans assigned by
CMS (if applicable). Include Leading Zeros. PDP plans
and MA-PDs without Segment_IDs should enter 000.

PHARMACY_NUMBER

Char(12)

NOT NULL

12-digit Pharmacy Number
• 10 digit NPI number with leading one and
zero
Plans may ONLY submit NPI numbers. National Council
for Prescription Drug Program (NCPDP) numbers will
not be recognized.

PRICE_ID

Number(3)

NOT NULL

References the Price File Grouping Number to be used at
this pharmacy.

BRAND_DISPENSING_FEE

Currency(12)
(Format:
$$$$$$$$cccc)

NOT NULL

In addition to the ingredient cost (product cost) at the point
of sale.

GENERIC_DISPENSING_FEE

Currency(12)
(Format:
$$$$$$$$cccc)

NOT NULL

In addition to the ingredient cost (product cost) at the point
of sale.

VACCINE_ADMINISTRATION_FEE

Currency(12)
(Format:
$$$$$$$$cccc)

NOT NULL

For vaccines only: In addition to the ingredient cost
(product cost), the maximum fee associated with the
administration of any covered vaccines at the pharmacies
in this Price_ID.

PREFERRED_STATUS_RETAIL

Number(1)

DEFAULT 0,
NOT NULL

Yes/No defines whether retail pharmacy is preferred, other
network, or network.
Acceptable values 0 or 1 (0=Other Network or Network
Pharmacy; 1=Preferred Pharmacy)

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Field Name

Type(Size)

NULL

Field Description

PHARMACY_RETAIL

NUMBER(1)

DEFAULT 1,
NOT NULL

Yes/No defines whether pharmacy is to be displayed in
retail (1 month supply) search.
Acceptable values 0 or 1 (0=Not Retail; 1=Retail)

PHARMACY_MAIL

NUMBER(1)

DEFAULT 0,
NOT NULL

Yes/No defines whether pharmacy is to be displayed in
mail-order (3 month supply) search.
Acceptable values 0 or 1 (0=Not Mail Order; 1=Mail
Order)

PHARMACY_LA_DRUGS

NUMBER(1)

DEFAULT 0,
NOT NULL

Yes/No defines whether a pharmacy qualifies as a
“specialty” pharmacy because it dispenses limited access
(LA) drugs.
Acceptable values 0 or 1 (0=Does not dispense Limited
Access Drugs; 1=Dispenses Limited Access Drugs)

PHARMACY_HI

NUMBER(1)

DEFAULT 0,
NOT NULL

Yes/No defines whether pharmacy dispenses home
infusion drugs.
Acceptable values 0 or 1 (0=Does not dispense Home
Infusion Drug; 1=Dispenses Home Infusion Drug)

PHARMACY_LTC

NUMBER(1)

DEFAULT 0,
NOT NULL

Yes/No defines whether pharmacy is considered a Long
Term Care pharmacy.
Acceptable values 0 or 1 (0=Not a Long Term Care
Pharmacy; 1=Long Term Care Pharmacy)

PREFERRED_STATUS_MAIL

Number(1)

DEFAULT 0,
NOT NULL

Yes/No defines whether mail-order pharmacy is preferred,
other network, or network.
Acceptable values 0 or 1 (0=Other Network or Network
Pharmacy; 1=Preferred Mail-Order Pharmacy)

FLOOR_PRICE

Currency(12)
(Format:
$$$$$$$$cccc)

NOT NULL

References the negotiated minimum price that a given
pharmacy will be paid for filling a prescription.
If a plan has not negotiated floor pricing at a
pharmacy, then FLOOR_PRICE should be
000000000000.
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Notes
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Submissions of pharmacy networks should be a full representation of your contracted Part D network as required under 42 CFR
§423.120(a).
There should only be one record per network pharmacy per plan. If multiple records are entered, subsequent records are ignored.
All PRICE_IDs listed in this file must exist in your Pricing File.
If a plan’s network has Preferred Network pharmacies, then there must also be Other (Non-Preferred) Network pharmacies, i.e., if a
sponsor has indicated “1” (meaning a Preferred Network Pharmacy), the PC file must also have a “0” (meaning Other Network
Pharmacy). If a plan’s network does not have Preferred Pharmacies, then all pharmacies should be “0” (meaning Network Pharmacy). As
defined in the regulation 42 CFR § 423.104, a preferred pharmacy means a network pharmacy that offers covered Part D drugs at
negotiated prices to Part D enrollees at lower levels of cost sharing than apply at a non-preferred pharmacy under its pharmacy network
contract with a Part D Sponsor.
PHARMACY_RETAIL and PHARMACY_MAIL are present to indicate whether a particular pharmacy offers drug sales at either a
standard retail supply or a mail order supply. If both services are offered, enter 1 for both fields. Otherwise, enter a 1 only for the
applicable pharmacy type.
o Example: If Pharmacy #101234567890 offers 30, 60, and 90 day retail, and 90 day mail order, the pharmacy cost file would be set up
like this:
S1234 001 000 101234567890 100 000000030000 000000015000 000000200000 0 1 1 0 0 0 0
Pharmacies that offer both retail and mail-order pharmacies can designate different preferred network pharmacy status. Please note that
preferred status of both retail and mail-order pharmacies must match sponsor’s CY2014 bid submission.
For pharmacies that offer both retail and mail-order pharmacies and have different dispensing fees for retail and mail-order pharmacies,
the highest dispensing fee should be entered (applies to both BRAND_DISPENSING_FEE and GENERIC_DISPENSING_FEE).
The maximum cost of administering any covered vaccine under the respective Price ID should be entered. If a vaccine requires a series of
administrations, include just the cost of 1 dose.
Floor pricing is used when a sponsor negotiates a minimum price that a given pharmacy will be paid for filling a prescription. Floor
pricing is often used for very low cost generics. Note: floor pricing is applied to drugs when full cost is less than the floor price. This full
cost includes the dispensing fee.
o A plan has a floor price of $3 in Price ID 101 at Pharmacy A. The plan would then submit pharmacy records in the following format:
H1001 001 000 101234567890 101 000000015000 000000015000 000000000000 010000 0 000000030000
If Drug Z has a full cost of $4 at Pharmacy A, the standard full cost will be displayed on Plan Finder.
If Drug Y has a full cost of $2.50 at Pharmacy A, the floor price of $3 will be display on Plan Finder.

Submission Frequency: First CY2014 submission will be on September 9, 2013. Thereafter, starting October 1st, 2013 organizations will
be required to submit pricing on a bi-weekly basis. Please refer to the CY2014 Calendar Year Pricing Data Submission Calendar for
more information. Organizations must submit required files each regular submission window even if no updates are required.

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PRICING FILE
Light Green Fields Indicate Unique Record Identifiers
Field Name

Type(Size)

NULL

Field Description

CONTRACT_ID

Char(5)

NOT NULL

References Organization’s Contract Number assigned by CMS

PRICE_ID

Number(3)

NOT NULL

Price File Grouping Number

NDC

Char(11)

NOT NULL

The appropriate 11 Digit NDC from the approved formulary and
supplemental excluded drug file, if applicable, representing the
drug/dose form combination

DAYS_SUPPLY

Number(2)

NOT NULL

The days supply applicable for this unit cost.
Acceptable values 30, 60, or 90

IS_MAIL

Number(1)

DEFAULT 0,
NOT NULL

Yes/No defines whether cost applies for dispensing at a Mail
Order pharmacy.
Acceptable values 0 or 1 (0=Cost applies at Retail; 1=Cost
applies at Mail Order)

UNIT_COST

Currency(12)
(Format:
$$$$$$$$cccc)

NOT NULL

Unit cost for given NDC less dispensing fee.

HAS_CEILING_COST

Number(1)

DEFAULT 0,
NOT NULL

Yes/No defines whether there is a ceiling cost provided in the
CP file.
Acceptable values 0 or 1 (0=No ceiling price; 1=Ceiling price
applies)

Submission Notes: For pricing display, the tool will display one cost for all NDCs of a given drug/dosage combination. Organizations will
submit records as described above with unit costs for the specific NDCs listed on the FRF at
http://www.cms.gov/PrescriptionDrugCovContra/03_RxContracting_FormularyGuidance.asp#TopOfPage that match your plan’s CMS approved
formulary.
For formulary drugs, organizations will submit unit cost pricing as described above. Organizations must submit unit costs for all drugs on their
CMS approved formulary. Enhanced alternative plans who have submitted a supplemental excluded drug file through HPMS should include the
pricing for those drugs in this file. Failure to submit pricing for a specific drug dose combination on the plan’s formulary will result in the
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display of a default drug price. Default drug prices are used to approximate cash prices. Submission of pricing for NDCs not on an organization’s
CMS approved formulary or not on the FRF will also result in the display default pricing.
Notes:
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This file determines the base unit cost of an NDC in the indicated Price ID.
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PRICE_ID is identified by the organization, within the following parameters:
o The lowest available PRICE_ID is 001
o PRICE_IDs should be assigned sequentially
o PRICE_IDs for Retail pharmacies should be between 100 and 999
o PRICE_IDs for Mail Order pharmacies should be between 200 and 299
o In the event that an organization has over 100 PRICE_IDs for a given type (retail or mail-order), additional PRICE_IDs should begin
sequentially in the next group of 100s where retail pharmacies are in the 300, 500, 700, 900 series, and mail-order pharmacies are in
the 400,600,800 series. The series containing 001 through 099 can also be used to accommodate more Price_IDs, either for retail or
mail-order.
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The pricing file is applied to the plan through the Pharmacy Cost file.
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Every drug from the formulary should be covered under each PRICE_ID. Exceptions are:
o Formulary drugs with restricted or limited access may be limited to PRICE_IDs used by “specialty” pharmacies.
o PRICE_IDs used only for “specialty” pharmacies dispensing limited access drugs should only contain records for drugs available at
pharmacies using that PRICE_ID.
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Unit pricing can be provided for 30, 60, and 90-day supplies at either a retail or mail-order pharmacy. Pricing should not be included for
any Days_Supply that are other than 30, 60, or 90. For example, 34-day supply is not supported.
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Plans must review their pricing data prior to submission. If a plan mistakenly enters 00000000000 in the Unit_Cost field, it is stating that
the drug/dose form (represented by an FRF related NDC or supplemental excluded drug file NDC) has a cost of zero and will display
default pricing. An NDC can be listed up to 6 times, as long as the Days_Supply and Is_Mail fields are unique (30-Retail, 30-Mail Order,
60-Retail, 60-Mail Order, 90-Retail-90, 90-Mail Order).
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Pricing should be included for all DAYS_SUPPLY and IS_MAIL benefit types that the plan offers. If drug pricing is not provided for a
benefit type that is defined as covered, the system will display pricing based on default pricing. If drug pricing is provided for a benefit
type that the plan has not defined as covered, those prices will be ignored.
o Example: If a pharmacy offers 30, 60, and 90 day supply at Retail, and 90 day supply at Mail Order under Price_ID 100. The
following records should be included in the Pricing File:
S1234 100 12345678910 30 0 000000080000 0
S1234 100 12345678910 60 0 000000125000 0
S1234 100 12345678910 90 0 000000160000 0
S1234 100 12345678910 90 1 000000100000 0
The above structure indicates that NDC 12345678910 has unit_cost of $8.00 for a 30-day retail supply, $12.50 for a 60-day retail
supply, $16.00 for a 90-day retail supply, and a $10.00 for a 90-day mail order supply. If the plan provided a unit_cost for this drug at
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a 30 or 60 day mail order pharmacy, those unit costs would be ignored. If the plan did not provide a price for this drug at 30 day
supply at retail, the Plan Finder would display a default price.
It is required for plans that have vaccines in their Part D Formulary to include pricing for vaccines in all PRICE_IDs, including those
PRICE_IDs specifically designated for Mail Order. Only exception will be for those PRICE_IDs used only for “specialty” pharmacies.
Please refer to the Pricing File layout for details.
Related NDCs contained on the CY2014 FRF must be used for the submission of Part D Pricing Files. For example, Zocor 10 MG and
Simvastatin 10 MG are represented on the CY2014 FRF as follows:
RXCUI

TTY

314231

SCD

104490

SBD

RxNorm Description
SIMVASTATIN 10 MG
ORAL TABLET
SIMVASTATIN 10 MG
ORAL TABLET
[ZOCOR]

Related NDC
68180047801

00006073554

When a plan submits pricing for Zocor 10 MG and Simvastatin 10 MG, the following guideline must be followed:
o For Simvastatin 10 MG, RXCUI 314231 is used for the HPMS formulary submission and the related NDC 68180047801is used for
the pricing file submission.
o For Zocor 10 MG, RXCUI 104490 is used for the HPMS formulary submission and the related NDC 00006073554 is used for the
pricing file submission.
o The plan would therefore submit pricing data for these two drugs as follows (assuming 30-day retail supply and no ceiling price):
H1001 101 68180047801 30 0 000000000846 0
H1001 101 00006073554 30 0 000000053128 0
For enhanced alternative plans, NDCs contained on approved HPMS supplemental excluded drug file shall continue to be utilized for
pricing purposes.
CMS may update the related NDCs associated with RXCUIs due to factors such as changes in the active or obsolete status of the FRF
NDCs. These changes will be part of CMS’ updates to the CY2014 FRF. The CY2014 FRF related NDCs may not be refreshed with
each monthly 2014 FRF updates; however, the related NDCs used for purposes of pricing file submissions will be refreshed no less than
quarterly. Plans will be required to submit updated pricing files that reflect the new related NDCs for RXCUIs on their last approved
HPMS formulary file. Subsequent to CMS’ release of an updated CY2014 FRF that contains changes to related NDCs, a general alert
will be sent to plans that will specify the effective date by which pricing files must be updated to reflect these related NDC changes.
Following the effective date, pricing data submitted for NDCs other than those on the current CY2014 FRF will not be used for display on
medicare.gov; default pricing will be displayed for those drugs. Effective dates will take into account other activities by CMS and plans
that may impact these updates, and will not be any sooner than the 2nd regular pricing data submission window following the release of an
updated CY2014 FRF.
The RXCUIs for diabetic supplies, prenatal vitamins, and fluoride preparations do not have related NDCs and do not display on the
Medicare Plan Finder. Therefore, no pricing should be submitted for diabetic supplies, prenatal vitamins, or fluoride preparations.
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If a plan is unable to provide pricing data for a related NDC, the plan should submit pricing based on the most comparable drug product.
The pricing files should still contain the related NDCs. Each NDC pricing should be based on the cost at the point of sale (POS).
Sponsors should not submit pricing based on the assumptions that a generic NDC will be substituted for a brand NDC. The following are
common examples of a “unit” for formulations:
o Pills: For oral tablets with unit of “EACH” (i.e. one unit of Simvastatin 20 mg is one tablet of Simvastatin 20 mg)
o Liquid: For liquid, unit can be defined in many different ways like one “vial”, “syringe”, or as “1MG” depending on the availability of
packaging for the drug (e.g., one unit of Fortaz INJ (All strengths) or Protonix INJ (40MG) is represented by a vial while one unit of
Aralast 500MG vial is represented by 1MG).
o Nebulizers: For inhalers or nebulizers, similar to liquid, unit can be identified in many different ways (e.g., one unit of albuterol is
represented by per “ML” while one unit of Proair HFA is represented by “GM” instead of bottle of vial).
Enhanced Alternative Plans: the NDC field for excluded drugs should be the plan-determined proxy NDC that is used in the supplemental
excluded drug file approved by CMS in HPMS.
For pharmacies that offer different pricing structure at the point-of-sale for different pharmacy services provided (i.e. Retail versus Mail
versus Long-term), the Unit_Cost field should reflect the applicable retail cost for retail pricing or the mail order price for mail order
pricing (applies to both brand and generic drugs and the Unit_Cost field). For example, if a pharmacy is marked as retail and home
infusion, the cost should reflect the cost the beneficiary will pay at retail. If the pharmacy is marked mail order and home infusion, the
cost should reflect the price the beneficiary would pay at mail order. Similarly, if a pharmacy is marked as retail, mail, and home
infusion, the cost submitted should be the applicable retail or mail order cost per the pricing file. It is important for sponsors to indicate if
the pharmacy dispenses retail, mail, or both in the PC File as well as using the IS_Mail indicator to ensure the proper unit cost display on
the MPF.
Ceiling pricing is used when a sponsor negotiates a maximum price that a given pharmacy will be paid for a specific NDC. Ceiling pricing
is often used for high cost generics. If ceiling pricing is provided in the CP file for an NDC, indicate this in the Has_Ceiling_Cost field by
entering “1”:
H1001 101 00001234567 30 0 000000050000 1
In the example above, a plan will provide ceiling cost for a 30-day Retail Supply of Drug A in Price ID 101 at Pharmacy Z.

Submission Frequency: First CY2014 submission will be on September 9, 2013. Thereafter, starting October 1st, 2013 organizations will
be required to submit pricing on a bi-weekly basis. Please refer to the CY2014 Calendar Year Pricing Data Submission Calendar for
more information. Organizations must submit required files each regular submission window even if no updates are required.

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CEILING PRICE FILE
Light Green Fields Indicate Unique Record Identifiers
Field Name

Type(Size)

NULL

Field Description

CONTRACT_ID

Char(5)

NOT NULL

References Organization’s Contract Number assigned by CMS

PRICE_ID

Number(3)

NOT NULL

Price File Grouping Number

NDC

Char(11)

NOT NULL

The appropriate 11 Digit NDC from the approved formulary and
supplemental excluded drug file, if applicable, representing the
drug/dose form combination

DAYS_SUPPLY

Number(2)

NOT NULL

The days supply applicable for this unit cost.
Acceptable values 30, 60, or 90

IS_MAIL

Number(1)

DEFAULT 0,
NOT NULL

Yes/No defines whether cost applies for dispensing at a Mail
Order pharmacy.
Acceptable values 0 or 1 (0=Cost applies at Retail; 1=Cost
applies at Mail Order)

CEILING_QTY

Number(6)
(Format:
###.###)

DEFAULT 0,
NOT NULL

Ceiling quantity for given NDC. If N/A, enter 000000.

CEILING_COST

Currency(12)
(Format:
$$$$$$$$cccc)

NOT NULL

Ceiling cost for given NDC less dispensing fee. If N/A, enter
000000000000.

Submission Notes: For pricing display, the tool will display one cost for all NDCs of a given drug/dosage combination. Organizations will
submit records as described above with unit costs for the specific NDCs listed on the FRF at
http://www.cms.gov/PrescriptionDrugCovContra/03_RxContracting_FormularyGuidance.asp#TopOfPage that match your plan’s CMS approved
formulary.
For formulary drugs, organizations will submit unit cost pricing as described above. Organizations must submit unit costs for all drugs on their
CMS approved formulary. Enhanced alternative plans who have submitted a supplemental excluded drug file through HPMS should include the
pricing for those drugs in this file. Failure to submit pricing for a specific drug dose combination on the plan’s formulary will result in the
display of a default drug price. Default drug prices are used to approximate cash prices. Submission of pricing for NDCs not on an organization’s
CMS approved formulary or not on the FRF will also result in the display default pricing.
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Notes:
•
This file determines the ceiling cost of an NDC in the indicated Price ID within a certain range of quantity.
•
The Ceiling Price file is applied to the plan through the Pricing File.
•
Every drug from the Pricing File that has indicated “1” in the Has_Ceiling_Price field should be priced within the Ceiling Price file.
•
Ceiling pricing is used when a sponsor negotiates a maximum price that a given pharmacy will be paid for a specific NDC. Ceiling pricing
is often used for high cost generics.
o A plan has a ceiling price of $100 for a 30-day Retail Supply of Drug A in Price ID 101 at Pharmacy Z with a dispensing fee of $2.
The plan would then submit a pricing file record in the following format:
H1001 101 00001234567 30 0 030000 000001000000
Since Drug A has a Unit_Cost of $5 (defined in the PF file), it would cost $152 for a quantity of 30 tablets ($5 * 30 quantity + $2
dispensing fee). Since there is a ceiling price of $100 for a 30-day supply, Plan Finder will display $100 as the full drug cost of Drug
A.
•
Ceiling price can be provided at varying quantity ranges for an NDC.
o Example: A pharmacy offers ceiling prices for a 30-day supply at Retail for Drug A. The ceiling price is $4 at quantity 180, and $6 at
quantity 360. That should be populated in the ceiling price file as:
S1234 100 12345678910 30 0 180000 000000040000
S1234 100 12345678910 30 0 360000 000000060000
Submission Frequency: First CY2014 submission will be on September 9, 2013. Thereafter, starting October 1st, 2013 organizations will
be required to submit pricing on a bi-weekly basis. Please refer to the CY2014 Calendar Year Pricing Data Submission Calendar for
more information. Organizations must submit required files each regular submission window even if no updates are required.

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