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

CY 2023 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

Field
Type

Maximu
m Field
Length

PA_Change_Type

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

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.

Always
Required

PA_Criteria_Change_Indicator

CHAR
Always
Required

1

If the PA criteria content did not change for this group
description compared to CY 2022, 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 indications for which the PA will be
approved that are not otherwise excluded from Part D
coverage.
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 Medically-accepted
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 2023 Prior Authorization File Record Layout
Maximum
Field
Length

Field Description

Field Name

Field Type

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 FDA-approved
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

Part B Prerequsite

CHAR
If
applicable

1

If a PA criteria requires a Part B drug before a Part D drug
then please enter “1” in this field”, otherwise enter “0”. This
field is applicable only to MAPD plans.

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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