CY2022 Plan Benefit Package (PBP) Software and Formulary Submission (CMS-R-262)

CY 2021 PA/ST 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 PA/ST Criteria Change Request during PA/ST Criteria Change Request Submission
Period.
Field Name

Field Type

Maximum
Field
Length

Always Required

Sample
Field Value(s)

00020005

8

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

2

Current UM Type values: PA or ST

PA

CHAR
FID

Field Description

Or 20005

CHAR
Current UM Type

Always Required

Reason for the UM Criteria
Change Request submitted.
Reason codes 1 to 6 and their
descriptions:

Reason for UM
Change

CHAR
Always Required

1

1 - Removal of 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
6 - Revision of existing criteria to
include a Part B drug (MAPDs
only)

1

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

Current UM Group
Description

CHAR
Always Required

100

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.

Antiemetics

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) semicolon (;).

CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
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