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

CY 2020 PAST Criteria Change Request Record Layout
Required File Format = ASCII File - Tab Delimited
Do not include a header record
Filename extension should be “.TXT”
Plan Users upload PAST Criteria Change Request during PAST Criteria Change Request Submission
Period.
Field Name
Formulary ID

Field Type
CHAR

Max.Field
Length

Field Description

8

Formulary ID (with or without leading zeros) for
which to request PA/ST edits.

00019005

Reason for the UM Criteria Change
Request submitted.

1

Always Required
Reason for UM
Change

CHAR

1

Always Required

Sample Field
Value(s)
Or 19005

Reason Codes 1 to 6 and their descriptions:


1 - Removal of a restriction



2 - Addition of drug(s) to existing
criteria



3 - Addition of a new indication



4 - Restriction based on a new Boxed
Warning/FDA Safety Communication



5 - Other extraordinary circumstance



Current UM
Type

CHAR

9

Always Required

6 - Revision of existing criteria to
include a Part B drug (MAPDs only)
Type of prior authorization or step therapy that
needs to be changed.

PA Type 1

PA and ST Type descriptions:




PA Type 1= Prior Authorization
Applies
PA Type 2 = Prior Authorization
Applies to New Starts Only
PA Type 3 = Part D vs. Part B
Prior Authorization Only




Current UM
Group
Description

CHAR
Always Required

100

ST Type 1 = Step Therapy Applies
ST Type 2 = Step Therapy Applies to
New Starts Only
Description of the prior authorization group
as it appears on the submitted formulary
file. This field must exactly match the value
entered in the
Prior_Authorization_Group_Desc field on
the Formulary File.
Or
Description of the step therapy group as it
appears on the submitted formulary file. This
field must exactly match the value entered in
the Step_Therapy_Group_Desc field on the
Formulary File.

CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
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Antiemetics

CY 2020 PAST Criteria Change Request Record Layout
UM Criteria
Element
Justification for
UM Change

CHAR
Always Required
CHAR
If applicable

50

4000

Description of the criteria of the prior
authorization or step therapy drug.

Required
Medical
Information

Comments or clinical justification for the
criteria change requests.

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) semi-colon (;).

CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
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