CY2023 Plan Benefit Package (PBP) Software and Formulary Submission (CMS-R-262)

CY 2020 Excluded Drugs File Record Layout
Required File Format = ASCII File - Tab Delimited
Do not include a header record
Filename extension should be “.TXT”
Field Name

RxCUI

Field Type

Number

Maximum
Field
Length

CHAR

RxCUI 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

Does the drug have a quantity limit
restriction?

0=

Always Required

Quantity_Limit_YN

CHAR

Sample Field
Value(s)

11

Always Required

Tier

Field Description

1

Always Required

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

No Quantity
Limits
1=
Quantity Limits
Apply

Quantity_Limit_Amo
unt

NUM
Sometimes Required

7

If Quantity_Limit_YN = 1 (Limits
Apply), enter the quantity limit unit
amount for a given prescription or
time period. The units for this
amount must be defined by a unit
of measure e.g. number of tablets,
milliliters, grams, etc.
If the Quantity_Limit_YN = 0 (No
Limits), leave this field blank.
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”.

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CY 2020 Excluded Drugs File Record Layout
Field Name

Quantity_Limit_Days

Field Type

NUM

Maximum
Field
Length
3

Sometimes Required

Field Description

Sample Field
Value(s)

Enter the number of days
associated with the quantity limit.

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

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

(e.g. 9 mls
every 30 days)

The maximum logical number that
will be accepted is “999”.
Capped_Benefit_YN

CHAR

1

Always Required
Capped_Benefit_Qu
antity

NUM

7

Sometimes Required

Does the drug have a capped
benefit limit?

0 = No

If Capped_Benefit_YN field is 1 =
Yes, enter the capped benefit limit
unit amount for a given prescription
or time period. The units for this
amount may be defined by a unit
measure e.g. number of tablets,
number of milliliters, number of
grams, etc.

365

1 = Yes

Note: The
Capped_Benefit_Quantity must be
greater than the
Quantity_Limit_Amount for a given
RxCUI.
If the Capped_Benefit_YN field is 0
= No, then leave this field blank
The maximum logical number that
will be accepted is “9999.99”.
Capped_Benefit_Da
ys

NUM

3

Sometimes Required

Enter the number of days
associated with the capped benefit
limit.

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

If the Capped_Benefit_YN field is 0
= No, then leave this field blank
Note: The Capped_Benefit_Days
must be greater than the
Quantity_Llimit_Days for a given
RxCUI.
The maximum logical number that
will be accepted is “999”.
Prior_Authorization_
YN

CHAR
Always Required

1

Is prior authorization required for
the drug?

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1 = Yes
0 = No

CY 2020 Excluded Drugs File Record Layout
Field Name

Prior_Authorization_
Criteria

Field Type

CHAR

Maximum
Field
Length
1500

Sometimes Required

Field Description

Sample Field
Value(s)

The description of the drug’s prior
authorization criteria.
If response to
Prior_Authorization_YN = 0 (No),
then leave this field blank.

Step_Therapy_YN

CHAR

1

Always Required
Step_Therapy_Criter
ia

CHAR

500

Sometimes Required

Does step therapy apply to this
drug?

1 = Yes
0 = No

The description of step therapy
protocol.
If response to Step_Therapy_YN =
0 (No), then leave this field blank.

Gap_Coverage_YN

NUM Always
Required

1

Is this drug covered in the gap?

1 = Yes

Response should be 1 (Yes)
regardless of whether this drug is
on a tier that is fully or partially
covered in the gap.

0 = No

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 (;).

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