CY2021 Plan Benefit Package (PBP) Software and Formulary Submission (CMS-R-262)

ADDITIONAL DEMONSTRATION
DRUG FILE RECORD LAYOUT
Required File Format = ASCII File - Tab Delimited
Do not include a header record.
Filename extension is “.TXT”
The additional demonstration drug (ADD) file must be submitted during the submission window
for the Part D supplemental files. This will be a comprehensive file that includes all non-Part D
products (whether prescription or over-the-counter (OTC)) that a Part D sponsor intends to cover
consistent with Part D rules (e.g. drugs that fall under Part D excluded drug categories) or that a
State requires to be covered under its Medicaid program. Therefore, this file will include drugs
that could otherwise be submitted on the supplemental excluded drug and/or supplemental OTC
files for non-demonstration applicants.
Please note that consistent with the Part D supplemental file submissions, there must be a
one-to-one relationship between additional demonstration drug and formulary files. This
means that only one formulary may be associated with each submitted ADD file.

Field Name
MMP_NDC

Field
Type

Field
Length

CHAR
Always
Required

11

Field Description
11-Digit National Drug Code

Sample
Field
Value(s)
00012533460

When no NDC is available enter the
applicable Uniform Product Code (UPC)
or Health Related Item Code (HRI).
Do not include any spaces, hyphens or
other special characters.

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW:
This information has not been publicly disclosed and may be privileged and confidential. It is for internal government
use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information.
Unauthorized disclosure may result in prosecution to the full extent of the law.
Page 1 of 4

Sample
Field
Value(s)

Field
Type

Field
Length

MMP_Tier

CHAR
Always
Required

1

The cost share tier level associated with
the drug (assumes that the drug is assigned
to only one tier value). Tier values 1-6 are
consistent with the selection of tier level
options available to data entry users in the
Plan Benefit Package software. Tier values
of 1 or 2 can only be selected for 2-tier
formulary designs.

1 = Tier Level 1
2 = Tier Level 2
3 = Tier Level 3
4 = Tier Level 4
5 = Tier Level 5
6 = Tier Level 6

MMP_QL_YN

CHAR
Always
Required

1

Does the drug have a quantity limit
(MMP_QL_YN) restriction?

0 = No Quantity
Limits
1 = Quantity
Limits Apply

MMP_QL_Amt

NUM
Sometimes
Required

7

If the MMP_QL_YN is” 1” (meaning
limits apply), enter the quantity limit
amount (MMP_QL_Amt) for a given
prescription or time period (typically 1
month). The units for this amount must be
defined by a unit of measure e.g. number
of tablets, milliliters, grams, etc. The
maximum logical number that will be
accepted is “9999.99”.

9 (e.g. 9 tablets)

Field Name

Field Description

If the MMP_QL_YN field is “0” (No),
then leave this field blank.
MMP_QL_Days

NUM
Sometimes
Required

3

The number of days (MMP_QL_Days)
associated with the quantity limit amount.
The maximum logical number that will be
accepted is “365”.

30 (e.g. 9
tablets every 30
days)

If the MMP_QL_YN field is “0” (No),
then leave this field blank.
MMP_CapBen_YN

CHAR
Always
Required

1

Does the drug have a capped benefit
(MMP_CapBen_YN) limit?

0 = No
1 = Yes

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW:
This information has not been publicly disclosed and may be privileged and confidential. It is for internal government
use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information.
Unauthorized disclosure may result in prosecution to the full extent of the law.
Page 2 of 4

Field Name
MMP_CapBen_Amt

Field
Type

Field
Length

NUM
Sometimes
Required

7

Field Description
If the MMP_CapBen_YN field is “1”
(meaning limits apply), enter the capped
benefit limit amount
(MMP_CapBen_Amt) for a given
prescription or time period. Plans may
elect to have a capped benefit amount
without a quantity limit. However if a
quantity limit applies as well, the capped
benefit amount must be greater than the
quantity limit amount. The units for this
amount must be defined by a unit measure
e.g. number of tablets, number of
milliliters, number of grams, etc. The
maximum logical number that will be
accepted is “9999.99”.

Sample
Field
Value(s)
180 (e.g. 180
tablets)

The capped benefit amount must be
greater than the quantity limit amount.
If the MMP_CapBen_YN field is “0”
(No), then leave this field blank.
MMP_CapBen_Days

NUM
Sometimes
Required

3

The number of days
(MMP_CapBen_Days) associated with the
capped benefit limit. The capped benefit
days must be greater than the quantity
limit days. The maximum logical number
that will be accepted is “365”.

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

If the MMP_CapBen_YN field is “0”
(No), then leave this field blank.
MMP_PA_YN

MMP_PA_Criteria

CHAR
Always
Required

1

CHAR
Sometimes
Required

3000

Is prior authorization (MMP_PA_YN)
required for the drug?

0 = No
1 = Yes

The description of the prior authorization
criteria (MMP_PA_criteria) for this drug.
If the MMP_PA_YN field is “0” (No),
then leave this field blank.

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW:
This information has not been publicly disclosed and may be privileged and confidential. It is for internal government
use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information.
Unauthorized disclosure may result in prosecution to the full extent of the law.
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Field Name

MMP_ST_YN

MMP_ST_Criteria

Field
Type

Field
Length

CHAR
Always
Required

1

CHAR
Sometimes
Required

1000

Field Description

Does step therapy (MMP_ST_YN) apply
to this drug?

Sample
Field
Value(s)

0 = No
1 = Yes

The description of the step therapy
protocol (MMP_ST_Criteria) for this
drug.
If the MMP_ST_YN field is “0” (No) then
leave this field blank.

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW:
This information has not been publicly disclosed and may be privileged and confidential. It is for internal government
use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information.
Unauthorized disclosure may result in prosecution to the full extent of the law.
Page 4 of 4