CY2016 Plan Benefit Package (PBP) Software and Formulary Submission (CMS-R-262)

CY 2015 Additional Demonstration Drug (ADD) File Record Layout

Required File Format = ASCII File - Tab Delimited
Do not include a header record.
Filename extension is “.TXT”

Field Name

Field Type

Field
Length

Field Description

Sample Field
Value(s)

FAD_FID

NUM
Always
Required

8

8-digit formulary ID (including leading
zeros) associated with this Additional
Demonstration Drug file.

00013999

FAD_NDC

CHAR
Always
Required

11

11-Digit National Drug Code

00012533460

When no NDC is available enter the
applicable Uniform Product Code (UPC)
or Health Related Item Code (HRI).
Do not include any spaces, hyphens or
other special characters.

FAD_OTC_RX

CHAR
Always
Required

1

Is this an over-the-counter (OTC) or
prescription (Rx) product?

0 = OTC
1 = Rx

FAD_Tier

CHAR
Always
Required

1

The cost share tier level associated with
the drug (assumes that the drug is
assigned to only one tier value). Tier
values 1-6 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

A tier level value of 1-6 is required for
all prescription drugs (FAD_OTC_RX =
1). If the FAD_OTC_RX = 0 and the
cost-sharing for the drug is not reflected
in the PBP submission on tiers 1-6 then
select tier “0”.
FAD_OTC_CS

CHAR
Sometimes
Required

25

If the FAD_Tier is” 0” (meaning other
OTC cost-sharing applies), enter the OTC
cost-sharing amount (FAD_OTC_CS) for
the drug based on a 1 month supply at a
retail pharmacy.

0= Other OTC
cost-sharing

$0.50

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW:
This information has not been publicly disclosed and may be privileged and confidential. It is for internal government
use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information.
Unauthorized disclosure may result in prosecution to the full extent of the law.

CY 2015 Additional Demonstration Drug (ADD) File Record Layout

Field Name

Field Type

Field
Length

Field Description

Sample Field
Value(s)

FAD_QL_YN

CHAR
Always
Required

1

Does the drug have a quantity limit
(FAD_QL_YN) restriction?

0 = No Quantity
Limits
1 = Quantity
Limits Apply

FAD_QL_Amt

NUM
Sometimes
Required

7

If the FAD_QL_YN is” 1” (meaning
limits apply), enter the quantity limit
amount (FAD_QL_Amt) 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. The maximum logical number
that will be accepted is “9999.99”.

9 (e.g. 9 tablets)

If the FAD_QL_YN field is “0” (No),
then leave this field blank.
FAD_QL_Days

NUM
Sometimes
Required

3

The number of days (FAD_QL_Days)
associated with the quantity limit amount.
The maximum logical number that will be
accepted is “365”.

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

If the FAD_QL_YN field is “0” (No),
then leave this field blank.
FAD_CapBen_YN

CHAR
Always
Required

1

Does the drug have a capped benefit
(FAD_CapBen_YN) limit?

0 = No
1 = Yes

FAD_CapBen_Amt

NUM
Sometimes
Required

7

If the FAD_CapBen_YN field is “1”
(meaning limits apply), enter the capped
benefit limit amount
(FAD_CapBen_Amt) for a given
prescription or time period. The units for
this amount must be defined by a unit
measure e.g. number of tablets, number of
milliliters, number of grams, etc. The
maximum logical number that will be
accepted is “9999.99”.

180 (e.g. 180
tablets)

The capped benefit amount must be
greater than the quantity limit amount.
If the FAD_CapBen_YN field is “0”
(No), then leave this field blank.

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW:
This information has not been publicly disclosed and may be privileged and confidential. It is for internal government
use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information.
Unauthorized disclosure may result in prosecution to the full extent of the law.

CY 2015 Additional Demonstration Drug (ADD) File Record Layout

Field Name

Field Type

Field
Length

Field Description

Sample Field
Value(s)

FAD_CapBen_Days

NUM
Sometimes
Required

3

The number of days
(FAD_CapBen_Days) associated with the
capped benefit limit. The maximum
logical number that will be accepted is
“365”.

365 (e.g. 180
tablets every 365
days)

If the FAD_CapBen_YN field is “0”
(No), then leave this field blank.
FAD_PA_YN

FAD_PA_Criteria

CHAR
Always
Required

1

CHAR
Sometimes
Required

3000

Is prior authorization (FAD_PA_YN)
required for the drug?

0 = No
1 = Yes

The description of the prior
authorization criteria
(FAD_PA_criteria) for this drug.
If the FAD_PA_YN field is “0” (No),
then leave this field blank.

FAD_ST_YN

FAD_ST_Criteria

CHAR
Always
Required

1

CHAR
Sometimes
Required

1000

Does step therapy (FAD_ST_YN) apply
to this drug?

0 = No
1 = Yes

The description of the step therapy
protocol (FAD_ST_Criteria) for this
drug.
If the FAD_ST_YN field is “0” (No), then
leave this field blank.

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW:
This information has not been publicly disclosed and may be privileged and confidential. It is for internal government
use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information.
Unauthorized disclosure may result in prosecution to the full extent of the law.