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

CY 2020 Prior Authorization 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 Prior Authorization
Group Descriptions. All records must have ADD for the Change_Type.
After the initial formulary submission period the file must include only changes.
Field Name

PA_Change_Type

Field
Type

Maximum
Field
Length

CHAR

3

Always
Required

Field Description

Defines the type of change that is being made to the
Prior Authorization File.
During the initial formulary submission period, all
rows must be “ADD.”
ADD = Add Group Description to file
UPD = Change fields for an existing Group
Description

Prior_Authorization_Group_Desc

CHAR

100

Always
Required

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.

PA_Criteria_Change_Indicator

CHAR
Always
Required

1

If the PA criteria content did not change for this group
description compared to CY 2019, please place a “0”
in this field. If this group description is new, or the
criteria content changed in any way (e.g. additional
restrictions), please place a “1” in this field”.

PA_Indication_Indicator

CHAR
Always
Required

1

This field must be populated with one of the values
below. This field is used to describe the indications
for which the PA will be approved.
1 = All FDA-approved Indications. This value cannot
be used if the drug that requires PA is subject to
Indication-Based Coverage (IBC).
2 = Some FDA-approved Indications Only. This value
is to be submitted for drugs that are subject to IBC.
3 = All Medically-accepted Indications. Drugs for
which the PA will be approved for all Part D
medically-accepted indications (FDA-approved and
compendia-supported) should be submitted with a 3.
4 = All FDA-approved Indications, Some Medicallyaccepted Indications. If the PA will only be approved
for specific off-label uses, a 4 should be submitted.
The additional off-label uses should be submitted in
the subsequent Off-Label Uses field.

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CY 2020 Prior Authorization File Record Layout
Maximum
Field Type Field Length

Field Name

Field Description

Off-label_Uses

CHAR
Required
only if a 4 is
entered for
PA_Indicatio
n_Indicator

3000

Enter the specific off-label uses for which the PA will
be approved. This field must not contain any FDAapproved indications.

Exclusion_Criteria

CHAR

2000

Describe any criteria (e.g. comorbid diseases,
laboratory data, etc.) that would result in the
exclusion of coverage for an enrollee.

2000

Enter laboratory, diagnostic, or other medical
information required for initiation or continuation of
the drug(s).

500

Enter age limitations or restrictions required for prior
authorization approval.

500

Description of prescriber attribute necessary for PA to
be considered, e.g. specialist in a field or registered
under a certain program.

100

Enter the duration for which the prior authorization
will be approved.

3000

Enter any other relevant criteria.

If
applicable
Required_Medical_Information

CHAR
If
applicable

Age_Restrictions

CHAR
If
applicable

Prescriber_Restrictions

CHAR
If
applicable

Coverage_Duration

CHAR
Always
Required

Other_Criteria

CHAR
If
applicable

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 (;).

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