CMS-10433 Prescriptions Drug Formulary Template

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Overview

Formulary Tiers
Drug Lists

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Sheet 1: Formulary Tiers

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

If macros are disabled, press and hold the ALT key and press the F, then I, and then N key. After that, select the Enable All Content option by pressing enter. (note that you can also press the C key to select "Enable All Content"). Instructions can be found in cells D1 through D5.

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 populated.

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*

Formulary URL*

Drug List ID*

Number of Tiers*

Drug Tier ID*

Drug Tier Type*

1 Month In Network Retail Pharmacy Copayment*

1 Month In Network Retail Pharmacy Coinsurance*

1 Month Out of Network Retail Pharmacy Benefit Offered?*

1 Month Out of Network Retail Pharmacy Copayment*

1 Month Out of Network Retail Pharmacy Coinsurance*

3 Month In Network Mail Order Pharmacy Benefit Offered?*

3 Month In Network Mail Order Pharmacy Copayment*

3 Month In Network Mail Order Pharmacy Coinsurance*

3 Month Out of Network Mail Order Pharmacy Benefit Offered?*

3 Month Out of Network Mail Order Pharmacy Copayment*

3 Month Out of Network Mail Order Pharmacy Coinsurance*

Required: Select the Formulary ID

Required: Enter the Formulary URL

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

Required: Select the number of Tiers

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

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

Required: Enter a copayment amount

Required: Enter a coinsurance amount

Required: Does this tier offer 1 Month Out of Network Retail Pharmacy Benefits?

Required if Offered: Enter a copayment amount

Required if Offered: Enter a coinsurance amount

Required: Does this tier offer 3 Month In Network Mail Order Pharmacy Benefits?

Required if Offered: Enter a copayment amount

Required if Offered: Enter a coinsurance amount

Required: Does this tier offer 3 Month Out of Network Mail Order Benefits?

Required if Offered: Enter a copayment amount

Required if Offered: Enter a coinsurance amount

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Sheet 2: Drug Lists

Drug Lists	All fields with an asterisk (*) are required. To validate the template, press the Validate button or Ctrl + Shift + I. To finalize, press Finalize button or Ctrl + Shift + F.
Instruction can be found in cells B1 through B5	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 populated.
	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*	Tier Level*	Prior Authorization Required	Step Therapy Required
Required: Enter the RXCUI	Required: Select the Tier this drug is in, or select NA if this drug is not a part of this Drug List	Required if Tier Level is not NA: Select "Yes" if Prior Authorization is Required	Required if Tier Level is not NA: Select "Yes" if Step Therapy is Required