CMS-10433 Prescriptions Drug Formulary Template

---

Overview

Formulary Tiers
Drug Lists

---

Sheet 1: Formulary Tiers

Prescription Drug Formulary Template

All fields with an asterisk (*) are required. To validate the template, press the Validate button or Ctrl + Shift + V. To finalize, press Finalize button or Ctrl + Shift + F.

Fields with an "#" indicate a field that would be moved or removed under this PRA package.

Click the Create Formulary IDs button (or Ctrl + Shift + C) to create Formulary IDs.

After creating Formulary IDs, select the ID from the drop down in Column A and 7 tiers will automatically be popoulated.

Select how many tiers a formulary uses from Number of Tiers and unused rows (tiers) will be greyed out.

Enter all RXCUIs on the Drug Lists sheet. To add more drug lists, click Add Drug List (Ctrl + Shift + A) and to delete the last drug list added press Delete Drug Lists (or Ctrl + Shift + D).

HIOS Issuer ID*

Issuer State*

Formulary ID* Required: Select the Formulary ID

Formulary URL* Required: Enter the Formulary URL

Drug List ID* Required: Select the Drug List ID (from Drug Lists sheet)

Number of Tiers* Required: Select the number of Tiers

Drug Tier ID* Required: The template will populate a Drug Tier ID 1-7

Drug Tier Type* Required: Select all the Drug Types included in this tier

1 Month In Network Retail Pharmacy Copayment*# Required: Enter a copayment amount

1 Month In Network Retail Pharmacy Coinsurance*# Required: Enter a coinsurance amount

1 Month Out of Network Retail Pharmacy Benefit Offered?*# Required: Does this tier offer 1 Month Out of Network Mail Order Pharmacy benefits?

1 Month Out of Network Retail Pharmacy Copayment*# Required if Offered: Enter a copayment amount

1 Month Out of Network Retail Pharmacy Coinsurance*# Required if Offered: Enter a coinsurance amount

3 Month In Network Mail Order Pharmacy Benefit Offered?*# Required: Does this tier offer 3 Month In Network Mail Order Pharmacy benefits?

3 Month In Network Mail Order Pharmacy Copayment*# Required if Offered: Enter a copayment amount

3 Month In Network Mail Order Pharmacy Coinsurance*# Required if Offered: Enter a coinsurance amount

3 Month Out of Network Mail Order Pharmacy Benefit Offered?*# Required: Does this tier offer 3 Month Out of Network Mail Order benefits?

3 Month Out of Network Mail Order Pharmacy Copayment*# Required if Offered: Enter a copayment amount

3 Month Out of Network Mail Order Pharmacy Coinsurance*# Required if Offered: Enter a coinsurance amount

---

Sheet 2: Drug Lists

Drug Lists
Fields with an "~" indicate a field that would be added under this PRA package.
All fields with an asterisk (*) are required. To validate the template, press the Validate button or Ctrl + Shift + V. To finalize, press Finalize button or Ctrl + Shift + F.
Click the Create Formulary IDs button (or Ctrl + Shift + C) to create Formulary IDs.
After creating Formulary IDs, select the ID from the drop down in Column A and 7 tiers will automatically be popoulated.
Select how many tiers a formulary uses from Number of Tiers and unused rows (tiers) will be greyed out.
Enter all RXCUIs on the Drug Lists sheet. To add more drug lists, click Add Drug List (Ctrl + Shift + A) and to delete the last drug list added press Delete Drug Lists (or Ctrl + Shift + D).
Drug List ID 1
RXCUI* Required: Enter the RXCUI	Tier Level* Required: Select the Tier this drug is in, or select NA if this drug is not a part of this Drug List	Prior Authorization Required Required if Tier Level is not NA: Select "Yes" if Prior Authorization is Required	Step Therapy Required Required if Tier Level is not NA: Select "Yes" if Step Therapy is Required	Quantity Limits Required if Tier Level is not NA:~ Select "Yes" if Coverage features Quantity Limits.	Fill Limits Required if Tier Level is not NA:~ Select "Yes" if Coverage features Fill Limits.	Pharmacy Restrictions Required if Tier Level is not NA:~ Select "Yes" if Coverage features Pharmacy Restrictions.	Over-the Counter Step Therapy Protocol Required if Tier Level is not NA:~ Select "Yes" if Coverage features OTC Step Therapy Protocols.