CY2019 Plan Benefit Package (PBP) Software and Formulary Submission (CMS-R-262)

Excluded Drugs File Record Layout
Required File Format = ASCII File - Tab Delimited
Do not include a header record
Filename extension should be “.TXT”
Field Name

NDC

Field Type

CHAR

Maximum
Field
Length

Field Description

Sample Field
Value(s)

11

11-Digit National Drug Code

00000333800

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

Does the drug have a quantity limit
restriction?

0 = No Quantity
Limits

Always Required
Tier

CHAR
Always Required

Quantity_Limit_YN

CHAR

1

Always Required

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

1 = Quantity
Limits Apply
Quantity_Limit_Amo
unt

NUM

7

Sometimes Required

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.

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_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_YN field is 0
(No), then leave this field blank.

(e.g. 9 mls
every 60 days)

The maximum logical number that
will be accepted is “999”.
Capped_Benefit_YN

CHAR
Always Required

1

Does the drug have a capped
benefit limit?

CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 1 of 3

0 = No
1 = Yes

Excluded Drugs File Record Layout
Field Name

Capped_Benefit_Qu
antity

Field Type

NUM

Maximum
Field
Length
7

Sometimes Required

Field Description

If Capped_Benefit_YN field is 1 =
Yes, enter the capped benefit limit
unit amount for a given prescription
or time period. The units for this
amount may be defined by a unit
measure e.g. number of tablets,
number of milliliters, number of
grams, etc.

Sample Field
Value(s)
365

Note: The
Capped_Benefit_Quantity must be
greater than the
Quantity_Limit_Amount for a given
NDC.
If the Capped_Benefit_YN field is 0
= No, then leave this field blank
The maximum logical number that
will be accepted is “9999.99”.
Capped_Benefit_Da
ys

NUM

3

Sometimes Required

Enter the number of days
associated with the capped benefit
limit.

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

If the Capped_Benefit_YN field is 0
= No, then leave this field blank
Note: The Capped_Benefit_Days
must be greater than the
Quantity_Llimit_Days for a given
NDC.
The maximum logical number that
will be accepted is “999”.
Prior_Authorization_
YN

CHAR

Prior_Authorization_
Criteria

CHAR

1

Always Required
1500

Sometimes Required

Is prior authorization required for
the drug?

1 = Yes
0 = No

The description of the drug’s prior
authorization criteria.
If response to
Prior_Authorization_YN = 0 (No),
then leave this field blank.

Step_Therapy_YN

CHAR
Always Required

1

Does step therapy apply to this
drug?

CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 2 of 3

1 = Yes
0 = No

Excluded Drugs File Record Layout
Field Name

Step_Therapy_Criter
ia

Field Type

CHAR

Maximum
Field
Length
500

Sometimes Required

Field Description

Sample Field
Value(s)

The description of step therapy
protocol.
If response to Step_Therapy_YN =
0 (No), then leave this field blank.

Gap_Coverage_YN

NUM Always
Required

1

Is this drug covered in the gap?

1 = Yes

Response should be 1 (Yes)
regardless of whether this drug is
on a tier that is fully or partially
covered in the gap.

0 = No

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 (;).

CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 3 of 3