CY2017 Plan Benefit Package (PBP) Software and Formulary Submission (CMS-R-262)

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
Change_Type

Field Type

Field
Length

Field Description

Sample Field
Value(s)

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

Always
Required

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_Type

CHAR
Always
Required

1

Does the drug have a quantity limit
restriction?

0 = Quantity Limits
Do Not Apply
1 = Daily Quantity
Limit
2 = Quantity Limit
Over Time

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Formulary Submission File Record Layout
Field Name

Field Type

Field
Length

Quantity_Limit_Amo
unt

NUM

7

Sometimes
Required

Field Description
If the Quantity_Limit_ Type = 0 (No
Limits), leave this field blank.

Sample Field
Value(s)
9

If the Quantity_Limit_Type = 1 (Daily
QL), enter the quantity limit unit amount
per day for a given prescription. The
units for this amount must be defined by
a unit of measure e.g. number of
tablets, milliliters, grams, etc.
If the Quantity_Limit_Type = 2 (QL Over
Time), enter the quantity limit unit
amount for a given 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 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_Days

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_Type field is 0 (No
Limits), then leave this field blank.

(e.g. 9 mls every 60
days)

If the Quantity_Limit_Type Type is 1
(Daily QL), then enter 1 in this field.
If the Quantity_Limit_Type field is 2 (QL
Over Time), then enter the time period
in days associated to the quantity
limit. The minimum number that will be
accepted is 2 and the maximum number
that will be accepted is “999”.

Prior_Authorization_
Type

CHAR
Always
Required

1

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

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Formulary Submission File Record Layout
Field Name
Prior_Authorization_
Group_Desc

Field Type

Field
Length

CHAR

100

Sometimes
Required

Field Description
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.

Sample Field
Value(s)
Antiemetics

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

CHAR

1

Is access to this drug limited to certain
pharmacies?

0 = No

100

Enter the name of the category for the
drug.

Analgesics

100

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
Therapeutic_Categor
y_Name

Therapeutic_Class_
Name

Step_Therapy_Type

CHAR
Always
Required
CHAR
Always
Required
CHAR

1

Always
Required

1 = Yes

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

Step_Therapy_Total
_Groups

NUM
Sometimes
Required

2

Enter the total number of step therapy
drug treatment groups in which the drug
is included.
If response to Step_Therapy_Type = 0
(No), then leave this field blank.
The maximum number that will be
accepted is “99.”

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Formulary Submission File Record Layout
NOTE: 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.
Field Name
Step_Therapy_Grou
p_Desc

Field Type

Field
Length

CHAR

100

Sometimes
Required

Field Description

Sample Field
Value(s)

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”

Step_Therapy_Gro
up_Desc = “Angina
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.
Step_Therapy_Step
_Value

NUM
Sometimes
Required

2

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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