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

CY 2021 UMGD Response Record Layout
Required File Format = ASCII File - Tab Delimited
Do not include a header record
Filename extension should be “.TXT”
Field Name

Field Type

Field
Length

Field Description

Formulary ID

NUM

8

Formulary ID (with or without leading zeros)
for which to submit UMGD response.

21000 or
00021000

UM Type

Always
Required
CHAR

2

UM Type values: PA or ST

PA

Always
Required
CHAR

100

PA or ST Group Description

Always
Required
CHAR

ALPHA-1
PROTEINASE
INHIBITORS

50

Valid values for PA Criteria Element are:

Required
Medical
Information

UM Group
Description
Criteria Element

Sometimes
Required

PA Indication Indicator
Off-Label Uses

Sample Field
Value(s)

Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Other Criteria
Note: If UM type is Step Therapy, enter NA
Plan Response
Option

NUM

1

Always
Required

Valid values for Plan Response Option field
are:

1

1=Remove Entire PAGD
2=Remove PA Element
3=Revise PA Criteria
4=Submit Clinical Justification

Plan Clinical
Justification/
Resubmission
Comment

CHAR
Sometimes
Required

4000

Comments or clinical justification (this field
is optional unless option 4 is chosen for the
plan response option)

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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