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

CY 2018 Formulary Submission 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 drugs in the formulary. All records must have

ADD for the Change_Type.

After the initial formulary submission period the file must include only changes.

Field Name

Field Type

Field
Length

Field Description

Sample Field
Value(s)

Change_Type

CHAR

3

Defines the type of change that is being
made to the formulary.

ADD = Add RxCUI
to formulary

During the initial formulary submission
period, all rows must be “ADD.”

DEL = Delete
RxCUI from
formulary

Always
Required

UPD = Change
fields in the existing
RxCUI
RxCUI

NUMBER
Always
Required

Tier_Level

CHAR

Maximum
of 8 digits

RxNorm concept unique identifier from
the active Formulary Reference File.

210597

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

1

Does the drug have a quantity limit
restriction?

0 = Quantity Limits
Do Not Apply
1 = Daily Quantity
Limit
2 = Quantity Limit
Over Time

Always
Required

Quantity_Limit_Type

CHAR
Always
Required

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CY 2018 Formulary Submission File Record Layout

Field Name

Field Type

Field
Length

Quantity_Limit_Amo
unt

NUM

7

Sometimes
Required

Field Description
If the Quantity_Limit_ Type = 0 (No
Limits), leave this field blank.

Sample Field
Value(s)
9

If the Quantity_Limit_Type = 1 (Daily
QL), enter the quantity limit unit amount
per day for a given prescription. The
units for this amount must be defined by
the unit of measure indicated by the
FRF.
If the Quantity_Limit_Type = 2 (QL Over
Time), enter the quantity limit unit
amount for a given time period when
the QL is not based on a maximal daily
dose. The units for this amount must be
defined by the unit of measure indicated
by the FRF.
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.

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

If the Quantity_Limit_Type field is 0 (No
Limits), then leave this field blank.

(e.g. 9 mls every 30
days)

If the Quantity_Limit_Type Type is 1
(Daily QL), then enter 1 in this field.
If the Quantity_Limit_Type field is 2 (QL
Over Time), then enter the time period
in days associated to the quantity
limit. The minimum number that will be
accepted is 2 and the maximum number
that will be accepted is “999”.
Prior_Authorization_
Type

CHAR
Always
Required

1

Is prior authorization required for the
drug?

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0 = No Prior
Authorization
1 = Prior
Authorization
Applies
2 = Prior
Authorization
Applies to New
Starts Only
3 = Part D vs. Part
B Prior
Authorization
Only

CY 2018 Formulary Submission File Record Layout

Field Name
Prior_Authorization_
Group_Desc

Limited_Access_YN

Field Type

Field
Length

Field Description

CHAR

100

Description of the drug’s prior
authorization group as it will appear on
the submitted prior authorization
attachment. The group name may
represent a drug category or class or
may simply be the name of the drug if
no other grouping structure applies.If
Prior_Authorization_Type is 0 (No) or 3
(Part D. vs. Part B Authorization Only),
then leave this field blank.

Antiemetics

1

Is access to this drug limited to certain
pharmacies?

0 = No
1 = Yes

100

Enter the name of the category for the
drug.

Analgesics

100

Enter the name of the class for the
drug.

Opioid Analgesics

1

Does step therapy apply to this drug?

0 = No Step
Therapy
Applies
1 = Step Therapy
Applies
2 = Step Therapy
Applies to New
Starts Only

2

Enter the total number of step therapy
drug treatment groups in which the
drug is included. If response to
Step_Therapy_Type = 0 (No), then
leave this field blank.
The maximum number that will be
accepted is “99.”
The remaining two fields described
below should be repeated as a group or
unit in the file.
For example, for a given drug used in
multiple Step Therapy programs, the
values for Step_Therapy_Group_Desc
= “CHF Therapy” and
Step_Therapy_Step_Value = 4 should
be included in adjacent columns in the
file. Likewise, the values for
Step_Therapy_Group_Desc = “Angina
Therapy” and
Step_Therapy_Step_Value = 1 should
be included in additional adjacent
columns in the file. Likewise, the values
for Step_Therapy_Group_Desc = “CVD
Therapy” and
Step_Therapy_Step_Value = 5 should
be included in additional adjacent
columns in the file.

3

Sometimes
Required

CHAR
Always
Required

Therapeutic_Categor
y_Name

Therapeutic_Class_
Name

Step_Therapy_Type

CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required

Step_Therapy_Total
_Groups

NUM
Sometimes
Required

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Sample Field
Value(s)

CY 2018 Formulary Submission File Record Layout

Field Name

Field Type

Field
Length

Field Description

Sample Field
Value(s)

Step_Therapy_Grou
p_Desc

CHAR
Sometimes
Required

100

Step_Therapy_Gro
up_Desc = “CHF
Therapy”
Step_Therapy_Gro
up_Desc = “Angina
Therapy”
Step_Therapy_Gro
up_Desc = “CVD
Therapy”

Step_Therapy_Step
_Value

NUM
Sometimes
Required

2

Description of step therapy drug
treatment group. Field should be
repeated in the record based upon
number of groups declared in
Step_Therapy_Total_Groups.
If response to Step_Therapy_Type = 0
(No), then leave this field blank. Note:
For a given RxCUI, each Group
Description must be unique.
Note: For each Step Therapy Group
Description, there must be a RxCUI
with a Step Therapy Value equal to 1.
Identifies the step number or level
within the sequence for the Step
Therapy Group. Field should be
repeated in the record based upon the
number of groups declared in
Step_Therapy_Total_Groups
AND in the same order as
Step_Therapy_Group_Desc
If response to Step_Therapy_Type = 0
(No), then leave this field blank.
The range of valid accepted values is 1
to 99.
Note: For each Step Therapy Group
Description, there must be a RxCUI
with a Step Therapy Value equal to 1.

Step_Therapy_Ste
p_Value = 4 (e.g.
Step 4 of 6)
Step_Therapy_Ste
p_Value = 1 (e.g.
Step 1 of 3)
Step_Therapy_Ste
p_Value = 5 (e.g.
Step 5 of 5)

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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