CMS-10433 Prescriptions Drug Formulary Template

OMB Control Number: 0938-1187
Expiration Date: XX/XX/20XX
fields with an asterisk
( * )please
are required.
To validate cell
the template,
the Validate button or Ctrl + Shift + I. To finalize, press Finalize button or Ctrl + Shift + F.
2023 Prescription Drug Formulary Template v12.0 [assistiveAlltechnology
users,
reference
A2 forpress
instructions]
Click
thethe
Create
Formulary
Ctrl
+ Shift
+ After
C) tothat,
create
Formulary
IDs.
Press TAB and directional arrow keys to read through the document. If macros are disabled, press and
hold
ALT key
and pressIDs
the button
F, then (or
I, and
then
N key.
select
the Enable
All Content option by pressing enter. (note that you can also press the C key to select "Enable All Content"). Instructions can be found in cells D1 through D5.
After creating Formulary IDs, select the ID from the drop down in Column A and 7 tiers will automatically be populated.
Select how many tiers a formulary uses from Number of Tiers and unused rows (tiers) will be greyed out.
Enter all RXCUIs on the Drug Lists sheet. To add more drug lists, click Add Drug List (Ctrl + Shift + A) and to delete the last drug list added press Delete Drug Lists (or Ctrl + Shift + D).
HIOS Issuer ID*
Issuer State*

Formulary ID*

Drug List ID*

Number of Tiers*

Drug Tier ID*

Drug Tier Type*

1 Month In
Network Retail
Pharmacy
Copayment*

Required:
Select the Formulary ID

Required:
Select the Drug List ID
(from Drug Lists sheet)

Required:
Select the number of Tiers

Required:
The template will populate a Drug
Tier ID 1-7

Required:
Select all the Drug Tier Types
included in this tier

Required: Enter a
copayment amount

1 Month Out of
Network Retail
Pharmacy Benefit
Offered?*

1 Month Out of 1 Month Out of
3 Month In Network
Network Retail Network Retail
Mail Order Pharmacy
Pharmacy
Pharmacy
Benefit Offered?*
Copayment*
Coinsurance*

3 Month In
Network Mail
Order
Pharmacy
Copayment*

3 Month In
Network Mail
Order
Pharmacy
Coinsurance*

3 Month Out of
Network Mail Order
Pharmacy Benefit
Offered?*

3 Month Out of 3 Month Out of
Network Mail
Network Mail
Order
Order
Pharmacy
Pharmacy
Copayment*
Coinsurance*

1 Month In
Network Retail
Pharmacy
Coinsurance*

Required:
Required:
Required:
Required if Offered: Required if Offered:
Required if Offered: Required if Offered:
Required if Offered: Required if Offered:
Required: Enter a Does this tier offer 1 Month
Does this tier offer 3 Month
Does this tier offer 3 Month
Enter a copayment Enter a coinsurance
Enter a copayment Enter a coinsurance
Enter a copayment Enter a coinsurance
coinsurance amount
Out of Network Retail
In Network Mail Order
Out of Network Mail Order
amount
amount
amount
amount
amount
amount
Pharmacy Benefits?
Pharmacy Benefits?
Benefits?

PRA DISCLOSURE:
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1187, expiration date is XX/XX/20XX. The time required to complete this information collection is estimated to
take up to 24.50 hours per issuer per year, including the time to review instructions, gather the information needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports
Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. ****CMS Disclosure**** Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden
approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact Nicole Levesque at [email protected].

fields with an asterisk
( * ) are
required.
To validate the
template,
press
the Validate button or Ctrl + Shift + I. To finalize, press Finalize button or Ctrl + Shift + F.
Drug Lists [assistiveAlltechnology
users,
please
reference
cell
A2 for
instructions]
Click
IDs button
(or Ctrl
Shift
+ C)
to create
Formulary
Press TAB and directional arrow keys
to the
readCreate
throughFormulary
the document.
Instructions
can+be
found
in cells
B1 through
B5. IDs.
After creating Formulary IDs, select the ID from the drop down in Column A and 7 tiers will automatically be populated.
Select how many tiers a formulary uses from Number of Tiers and unused rows (tiers) will be greyed out.
Enter all RXCUIs on the Drug Lists sheet. To add more drug lists, click Add Drug List (Ctrl + Shift + A) and to delete the last drug list added press Delete Drug Lists (or Ctrl + Shift + D).

Drug List ID 1
RXCUI*

Tier Level*

Prior Authorization
Required

Step Therapy Required

Required:
Enter the RXCUI

Required:
Select the Tier this drug is in, or
select NA if this drug is not a
part of this Drug List

Required if Tier Level is not
NA:
Select "Yes" if Prior
Authorization is Required

Required if Tier Level is not
NA:
Select "Yes" if Step Therapy is
Required