Copy of PDE Inbound File Layout Final_20250101

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HDR
FIELD NO. FIELD NAME
1
RECORD ID

NCPDP FIELD

POSITION
1-3

PICTURE
X(3)

LENGTH
3

NCPDP, CMS OR PDFS DEFINED
PDFS

DEFINITION / VALUES
"HDR"

2

SUBMITTER ID

4-9

X(6)

6

CMS

Unique ID assigned by CMS.

3

FILE ID

10 - 19

X(10)

10

PDFS

4
5

TRANS DATE
PROD TEST CERT IND

20 - 27
28 - 31

9(8)
X(4)

8
4

PDFS
PDFS

Unique ID provided by Submitter.
Same ID cannot be used within 12
months.
Date of file transmission to PDFS.
PROD, TEST, or CERT

6

FILLER

32 - 1000

X(969)

969

N/A

SPACES

BHD
FIELD NO.
FIELD NAME
1
RECORD ID
2

SEQUENCE NO

3
4
5

CONTRACT NO
PBP ID
FILLER

NCPDP FIELD

POSITION

PICTURE

LENGTH

NCPDP, CMS OR PDFS DEFINED

1-3

X(3)

3

PDFS

4 - 10

9(7)

7

PDFS

11 - 15
16 - 18
19 - 1000

X(5)
X(3)
X(982)

5
3
982

CMS
CMS
N/A

DEFINITION / VALUES
"BHD"
Must start with 0000001
Assigned by CMS
Assigned by CMS
SPACES

DET

FIELD NO.
1
2

FIELD NAME

NCPDP FIELD

POSITION

51 - 70

X(20)

20

302-C2

71 - 90

X(20)

20

RECORD ID
SEQUENCE NO

1-3
4 - 10
11 - 50

PICTURE
X(3)
9(7)

3
7

CLAIM CONTROL NUMBER
MEDICARE BENEFICIARY
IDENTIFIER
CARDHOLDER ID

6

PATIENT DATE OF BIRTH
(DOB)

304-C4

91 - 98

9(8)

8

7

PATIENT GENDER CODE

305-C5

99 - 99

9(1)

1

8

DATE OF SERVICE (DOS)

9

PAID DATE

10

PRESCRIPTION SERVICE
REFERENCE NO

402-D2

116 - 127

11

PRODUCT SERVICE ID

407-D7 or
489- TE

128 - 167

12

FILLER

13

SERVICE PROVIDER ID
QUALIFIER

401-D1

100 - 107

14

SERVICE PROVIDER ID

15

FILL NUMBER

16

DISPENSING STATUS

17

COMPOUND CODE

18

DISPENSE AS WRITTEN (DAW)
PRODUCT SELECTION CODE

19

ORIGINALLY PRESCRIBED
QUANTITY

108 - 115

X(40)

LENGTH

3
4
5

9(8)
9(8)

40

8
8

NCPDP, CMS OR PDFS
DEFINITION / VALUES
DEFINED
PDFS
"DET"
PDFS
Must start with 0000001
A number assigned by the plan to identify the prescription drug event. This is an optional field.
CMS
*non-numeric values should be left justified.
Medicare Health Insurance Claim Number (HICN) or Railroad Retirement Board (RRB) number or
CMS
Medicare Beneficiary Identifier (MBI).
Plan identification of the enrollee. Assigned by plan.
NCPDP
*non-numeric values should be left justified.
Optional field.
NCPDP
If populated, the format is CCYYMMDD.
Valid values are:
1=M
NCPDP
2=F
NCPDP
CCYYMMDD
The date the plan paid the pharmacy for the prescription drug.
Mandatory for Fallback plans.
CMS
Optional for all other plans. If populated, the format is CCYYMMDD.
Applies to all PDEs with a DOS >= 01/01/2011.
NCPDP
Field is right justified and filled with 5 leading zeros.
Submit 11 digit NDC only. Fill the first 11 positions, no spaces or hyphens, followed by 29 spaces. Format
is MMMMMDDDDPP. DDPS will reject the following billing codes for compounded legend and/or
NCPDP
scheduled drugs with a value of:
99999999999, 99999999992, 99999999993, 99999999994, 99999999995, or 99999999996.
CMS
SPACES
The type of pharmacy provider identifier used in field 14. Valid values are:
01 = National Provider Identifier (NPI)
06 = UPIN
07 = NCPDP Provider ID
NCPDP
08 = State License
11 = Federal Tax Number
99 = Other (Reported Gap Discount must = 0)
Mandatory for standard format. For standard format, valid values are 01 or 07.
For non-standard format any of the above values are acceptable.
When Plans report Service Provider ID Qualifier = 99, populate Service Provider ID with the default value
PAPERCLAIM defined for the TrOOP Facilitation Contract. When Plans report Federal Tax Number (TIN),
NCPDP
use the following format: ex: 999999999 (do not report embedded dashes).
* non-numeric values should be left justified.
Valid values are:
0–99
NCPDP
If unavailable, use zero.

9(12)

12

X(40)

40

168 - 197

X(30)

30

202-B2

198 - 199

X(2)

2

201-B1

200 - 214

X(15)

15

403-D3

215 - 216

9(2)

2

343-HD

217 - 217

X(1)

1

NCPDP

406-D6

218 - 218

9(1)

1

NCPDP

408-D8

219 - 219

X(1)

1

NCPDP

446-EB

NCPDP

220 - 229

9(7)V999

10

442-E7

230 - 239

9(7)V999

10

21

FILLER

240 - 242

X(3)

3

CMS

22

DAYS SUPPLY

405-D5

243 - 245

9(3)

3

NCPDP

23

PRESCRIBER ID QUALIFIER

466-EZ

246 - 247

X(2)

2

NCPDP

24

PRESCRIBER ID

411-DB

248 - 282

X(35)

35

NCPDP

25

DRUG COVERAGE STATUS
CODE

283 - 283

X(1)

1

CMS

26

ADJUSTMENT DELETION
CODE

284 - 284

X(1)

1

CMS

27

NON- STANDARD FORMAT
CODE

285 - 285

X(1)

1

CMS

28

PRICING EXCEPTION CODE

286 - 286

X(1)

1

CMS

29

PART D MODEL INDICATOR

287 - 288

X(2)

2

CMS

20

QUANTITY DISPENSED

NCPDP

On PDEs with a DOS >= 01/01/2011, must be a SPACE.
On PDEs with a DOS < 01/01/2011, valid values are:
SPACE = Not Specified
P = Partial Fill
C = Completion of Partial Fill
Valid values are:
0 = Not specified
1 = Not a Compound
2 = Compound
Valid values are:
0 = No Product Selection Indicated
1 = Substitution Not Allowed by Prescriber
2 = Substitution Allowed - Patient Requested Product Dispensed
3 = Substitution Allowed - Pharmacist Selected Product Dispensed
4 = Substitution Allowed - Generic Drug Not in Stock
5 = Substitution Allowed - Brand Drug Dispensed as Generic
6 = Override
7 = Substitution Not Allowed - Brand Drug Mandated by Law
8 = Substitution Allowed - Generic Drug Not Available in Marketplace
9 = Other
Required for PDEs with a DOS >= 01/01/2025. For Schedule II drugs that are reported as standard,
electronically-submitted PDEs, this field must contain the originally prescribed quantity. Must be zero for
DOS < 01/01/2025, or for non-Schedule II PDEs.
Number of Units, Grams, Milliliters, other. If compounded item, total of all ingredients will be supplied as
Quantity Dispensed; report quantity in the unit form of the final state of the resulting compound.
SPACES
Valid values are:
0 - 999
The type of prescriber identifier used in field 24.
For PDEs with a DOS >= 01/01/2013, the value of 01 is mandatory for all formats.
For PDEs with a DOS < 01/01/2013, valid values are:
01 = National Provider Identifier (NPI)
06 = UPIN
08 = State License Number
12 = Drug Enforcement Administration (DEA) number
Mandatory for standard format.
Mandatory for Non-Standard Format for PDEs with a DOS >= 01/01/2012
For PDEs with a DOS < 01/01/2012, optional when the Non-Standard Format Code = B, C, P, or X, but
must be a valid value if present.
Mandatory
* non-numeric values should be left justified.
Coverage status of the drug under Part D and/or the PBP. Valid values are:
C = Covered
E = Supplemental drugs (reported by Enhanced Alternative plans only)
O = Over-the-counter drugs
Valid values are:
A = Adjustment
D = Deletion
SPACE = Original PDE
Format of claims originating in a non-standard format. Valid values are:
A = Medicaid subrogation claim
B = Beneficiary submitted claim
C = COB claim
P = Paper claim from provider
X = X12 837
SPACE = NCPDP electronic format
Valid Values are:
M= Medicare as Secondary
Payer
O = Out-of-network pharmacy (Medicare is Primary)
SPACE = In-network pharmacy (Medicare is Primary)
Plan reported value indicating the Part D Model type applied to the PDE. Valid values are:
01 = Value-based Insurance Design (VBID) Model
07 = Part D Senior Savings (PDSS) Model
SPACES = No Part D Model applied
For PDSS model eligible PDEs submitted by Plans participating in the PDSS Model, this field is required to
be populated with 07 on PDEs with a DOS >= 01/01/2022.
For VBID model eligible PDEs submitted by Plans participating in a VBID Model, this field is required to be
populated with 01 on PDEs with a DOS >= 01/01/2023. This field is optional for VBID eligible PDEs with a
DOS < 01/01/2023.
Applies to covered drugs only.

30

FILLER

289 - 314

X(26)

26

CMS

31

CATASTROPHIC COVERAGE
CODE

315 - 315

X(1)

1

CMS

32

INGREDIENT COST PAID

506-F6

316 - 326

S9(9)V99

11

NCPDP

507-F7

33

DISPENSING FEE PAID

327 - 337

S9(9)V99

11

NCPDP

34

TOTAL AMOUNT ATTRIBUTED
TO SALES TAX

338 - 348

S9(9)V99

11

CMS

35

ESTIMATED REMUNERATION
AT POS AMOUNT (ERPOSA)

349 - 359

S9(9)V99

11

CMS

36

PHARMACY PRICE
CONCESSIONS AT POS

360 - 370

S9(9)V99

11

CMS

37

VACCINE ADMINISTRATION
FEE OR ADDITIONAL
DISPENSING FEE

371 - 381

S9(9)V99

11

CMS

38

FILLER

382 - 436

X(55)

55

CMS

39

GROSS DRUG COST BELOW
OUT-OF-POCKET THRESHOLD
(GDCB)

437 - 447

S9(9)V99

11

CMS

40

GROSS DRUG COST ABOVE
OUT-OF-POCKET THRESHOLD
(GDCA)

448 - 458

S9(9)V99

11

CMS

41

PATIENT PAY AMOUNT

459 - 469

S9(9)V99

11

NCPDP

42

OTHER TROOP AMOUNT

470 - 480

S9(9)V99

11

CMS

For non-model PDEs submitted by Plans participating in a Part D Model, and for PDEs submitted by Plans
that are not participating in a Part D Model, this field must contain SPACES.
SPACES
Optional for PDEs with a DOS >= 01/01/2011. Mandatory on PDEs with a DOS < 01/01/2011. Valid values
are:
A = Attachment Point met on this event
C = Above Attachment Point
SPACE = Attachment Point not met
Amount the pharmacy is paid for the drug itself. Dispensing fees or other costs are not included in this
amount.
Amount the pharmacy is paid for dispensing the medication. The fee may be negotiated with pharmacies
at the plan or PBM level. Additional fees may be charged for compounding/mixing multiple drugs. Do
not include administrative fees. Vaccine Administration Fee or Additional Dispensing Fee is reported in
Field 37.
Depending on jurisdiction, sales tax may be calculated in different ways or distributed in multiple NCPDP
fields. Plans will report the total sales tax for the PDE regardless of how the tax is calculated or reported
at point-of-sale.
For PDEs with a DOS >= 01/01/2025, this field contains the estimated amount of remuneration that are
not pharmacy price concessions that the plan sponsor is required to apply, or has elected to apply, to the
negotiated price as a reduction in the drug price made available to the beneficiary at the point of sale
(POS). This estimate includes the rebate or other price concession amount that the plan sponsor expects
to receive from a pharmaceutical manufacturer or other non-pharmacy entity and has elected to apply to
the negotiated price. This estimate does not include pharmacy price concessions applied at the point of
sale, which must be reported in the “Pharmacy Price Concessions at POS” field.
For PDEs with a DOS >= 01/01/2024 and a DOS <= 12/31/2024, this estimate must reflect the maximum
amount of any contingent payments or adjustments that the plan sponsor might receive from a network
pharmacy that would serve to decrease the total amount that the plan sponsor pays for the drug, i.e., all
pharmacy price concessions. This estimate must also reflect the rebate or other price concession amount
that the plan sponsor expects to receive from a pharmaceutical manufacturer or other non-pharmacy
entity and has elected to apply to the negotiated price.
For PDEs with a DOS < 01/01/2024, this field must contain the estimated amount of rebates and/or other
price concessions that the plan sponsor is required to apply, or has elected to apply, to the negotiated
price as a reduction in the drug price made available to the beneficiary at the POS.
When there is no rebate or price concession made available to the beneficiary at the POS, this field may
be zero dollars. This field must contain a positive dollar amount; the field may never be negative.
For PDEs with a DOS >= 01/01/2025, this field must contain the maximum amount of any contingent
payments or adjustments that the plan sponsor might receive from a network pharmacy that would
serve to decrease the total amount that the plan sponsor pays for the drug, i.e., all pharmacy price
concessions. All other estimated remuneration applied at the POS must be reported in the “Estimated
Remuneration at POS Amount (ERPOSA)” field. This field must contain a positive dollar amount, or zero
dollars when there is no price concession applied at the POS; the field may never be negative. For PDEs
with a DOS < 01/01/2025, this field must be zero.
Amount the plan paid the pharmacy for administering a vaccination. For PDEs with a DOS >= 01/01/2008,
a value must be reported when there is a vaccine administration fee or additional Emergency Use
Authorization (EUA) dispensing fee charged. For PDEs with a DOS < 01/01/2008, this field must be zero.
This field may also include amounts of additional dispensing fees paid for EUA oral antiviral drugs
procured by the U.S. Government, over and above what was reported in the “Dispensing Fee Paid” field.
SPACES
Reports covered drug cost at or below the out of pocket threshold. Any remaining portion of covered
drug cost is reported in GDCA. Covered drug cost is the sum of Ingredient Cost Paid + Dispensing Fee
Paid + Total Amount Attributed to Sales Tax + Vaccine Administration Fee or Additional Dispensing Fee.
For PDEs with a DOS < 01/01/2011, when the Catastrophic Coverage Code = SPACE, this field equals the
sum of Ingredient Cost Paid + Dispensing Fee Paid + Total Amount Attributed to Sales Tax + Vaccine
Administration Fee or Additional Dispensing Fee. When the Catastrophic Coverage Code = A, this field
equals the portion of Ingredient Cost Paid + Dispensing Fee Paid + Total Amount Attributed to Sales Tax +
Vaccine Administration Fee or Additional Dispensing Fee falling at or below the OOP threshold. Any
remaining portion is reported in GDCA. This amount increments the Total Gross Covered Drug Cost
Accumulator amount.
Reports covered drug cost above the out of pocket threshold. Any remaining portion of covered drug
cost is reported in GDCB. Covered drug cost is the sum of Ingredient Cost Paid + Dispensing Fee Paid +
Total Amount Attributed to Sales Tax + Vaccine Administration Fee or Additional Dispensing Fee.
For PDEs with a DOS < 01/01/2011, when the Catastrophic Coverage Code = C, this field equals the sum
of Ingredient Cost Paid + Dispensing Fee Paid + Total Amount Attributed to Sales Tax + Vaccine
Administration Fee or Additional Dispensing Fee above the OOP threshold. When the Catastrophic
Coverage Code = A, this field equals the portion of Ingredient Cost Paid + Dispensing Fee Paid + Total
Amount Attributed to Sales Tax + Vaccine Administration Fee or Additional Dispensing Fee falling above
the OOP threshold. Any remaining portion is reported in GDCB. This amount increments the Total Gross
Covered Drug Cost Accumulator amount.

43

LOW INCOME COST SHARING
SUBSIDY AMOUNT (LICS)

481 - 491

S9(9)V99

11

CMS

Payments made by the beneficiary or by family or friends at point of sale. This amount increments the
True Out-of-Pocket (TrOOP) Accumulator amount.
Other health insurance payments by TrOOP-eligible other payers (e.g., SPAPs). This field records all thirdparty payments that contribute to a beneficiary’s TrOOP except LICS, Patient Pay Amount, and the
Reported Gap Discount (for PDEs with a DOS < 01/01/2025) or Manufacturer Discount (for PDEs with a
DOS >= 01/01/2025). This amount increments the True Out-of-Pocket Accumulator amount. For PDEs
with a DOS >= 01/01/2023 and DOS <= 12/31/2023, this field may contain the Inflation Reduction Act
Subsidy Amount (IRASA). When this field contains IRASA, the Other TrOOP Amount Indicator field must
be reported with a value of S or B.
Amount the plan advanced at point-of-sale due to a beneficiary's LI status. This amount increments the
True Out-of-Pocket Accumulator amount.

44

PATIENT LIABILITY
REDUCTION DUE TO OTHER
PAYER AMOUNT (PLRO)

492 - 502

S9(9)V99

11

CMS

Amount by which patient liability is reduced due to payment by other payers that are not TrOOP-eligible
and do not participate in Part D.

45

COVERED D PLAN PAID
AMOUNT (CPP)

503 - 513

S9(9)V99

11

CMS

505-F5

46

NON COVERED PLAN PAID
AMOUNT (NPP)

514 - 524

S9(9)V99

11

CMS

47

GOVERNMENT PAY SUBSIDY

525 - 535

S9(9)V99

11

CMS

48

REPORTED MANUFACTURER
DISCOUNT

536 - 546

S9(9)V99

11

CMS

49

REPORTED GAP DISCOUNT

547 - 557

S9(9)V99

11

CMS

50

FILLER

558 - 623

X(66)

66

CMS

51

TOTAL GROSS COVERED
DRUG COST ACCUMULATOR

624 - 634

S9(9)V99

11

CMS

52

FILLER

635 - 636

X(2)

2

CMS

53

TRUE OUT-OF-POCKET
ACCUMULATOR

637 - 647

S9(9)V99

11

CMS

54

FILLER

648 -649

X(2)

2

CMS

55

DEDUCTIBLE ACCUMULATOR

650 - 660

S9(9)V99

11

CMS

56

OTHER TROOP AMOUNT
INDICATOR

661 - 661

X(1)

1

CMS

57

BEGINNING BENEFIT PHASE

662 - 662

X(1)

1

CMS

58

ENDING BENEFIT PHASE

663 - 663

X(1)

1

CMS

59

PRESCRIPTION ORIGIN CODE

664 - 664

X(1)

1

NCPDP

60

DATE ORIGINAL CLAIM
RECEIVED

665 - 672

9(8)

8

CMS

61

CLAIM ADJUDICATION BEGAN
TIMESTAMP

673 - 698

X(26)

26

CMS

62

BRAND/GENERIC CODE

699 - 699

X(1)

1

CMS

63

TIER

700 - 700

X(1)

1

CMS

64

FORMULARY CODE

701 - 701

X(1)

1

CMS

65

PHARMACY SERVICE TYPE

147-U7

702 - 703

X(2)

2

NCPDP

66

PATIENT RESIDENCE

384-4X

704 - 705

X(2)

2

NCPDP

67

SUBMISSION TYPE CODE 1

D17-K8

706 - 707

X(2)

2

NCPDP

68

SUBMISSION TYPE CODE 2

D17-K8

708 - 709

X(2)

2

NCPDP

69

SUBMISSION TYPE CODE 3

D17-K8

710 - 711

X(2)

2

NCPDP

70

SUBMISSION TYPE CODE 4

D17-K8

712 - 713

X(2)

2

NCPDP

71

SUBMISSION TYPE CODE 5

D17-K8

714 - 715

X(2)

2

NCPDP

72

SUBMISSION CLARIFICATION
CODE 1

420-DK

716 - 718

X(3)

3

NCPDP

73

SUBMISSION CLARIFICATION
CODE 2

420-DK

719 - 721

X(3)

3

NCPDP

74

SUBMISSION CLARIFICATION
CODE 3

420-DK

722 - 724

X(3)

3

NCPDP

75

SUBMISSION CLARIFICATION
CODE 4

420-DK

725 - 727

X(3)

3

NCPDP

76

SUBMISSION CLARIFICATION
CODE 5

420-DK

728 - 730

X(3)

3

NCPDP

77

LTPAC DISPENSE FREQUENCY

C91-KK

731 - 732

X(2)

2

NCPDP

78

ADJUSTMENT REASON CODE
QUALIFIER

733 - 733

X(1)

1

CMS

79

ADJUSTMENT REASON CODE

734 - 745

X(12)

12

CMS

80

FILLER

746 - 1000

X(255)

255

CMS

419-DJ

The net Medicare covered amount which the plan has paid for a Part D covered drug under the Basic
benefit. Amounts paid for supplemental drugs, supplemental cost-sharing, and Over-the-Counter drugs
are excluded from this field.
The amount of plan payment for enhanced alternative benefits (cost sharing fill-in and/or non-Part D
drugs). This dollar amount is excluded from risk corridor calculations.
Required for PDEs with a DOS >= 01/01/2025, the government pay selected drug subsidy amount. On
PDEs with a DOS < 01/01/2025, must be zero.
Required for PDEs with a DOS >= 01/01/2025. The reported amount that the plan sponsor advanced at
point of sale for the Manufacturer Discount for applicable drugs. On PDEs with a DOS < 01/01/2025,
must be zero. This amount will not increment the True Out-of-Pocket Accumulator amount.
The reported amount that the plan sponsor advanced at point of sale for the Gap Discount for applicable
drugs. Required on PDEs with a DOS >= 01/01/2011 and a DOS <= 12/31/2024. On PDEs with a DOS <
01/01/2011 or PDEs with a DOS >= 01/01/2025, must be zero. This amount increments the True Out-ofPocket Accumulator amount.
SPACES
Sum of the beneficiary's covered drug costs for the benefit year known immediately prior to adjudicating
the claim. Required on PDEs with a DOS >= 01/01/2011. On PDEs with a DOS < 01/01/2011, must be
zero.
SPACES
Sum of the beneficiary's incurred costs for the benefit year known immediately prior to adjudicating the
claim. Required on PDEs with a DOS >= 01/01/2011. On PDEs with a DOS < 01/01/2011, must be zero.
SPACES
Sum of the beneficiary's deductible amount for the benefit year known immediately prior to adjudicating
the claim. Required for PDEs with a DOS >= 01/01/2025. On PDEs with a DOS < 01/01/2025, must be
zero.
This code is used for PDEs with a DOS >= 01/01/2023 and a DOS <= 12/31/2023, when the Other TrOOP
Amount includes Inflation Reduction Act Subsidy Amount (IRASA) dollars for benefit year 2023.
Valid values are:
B = indicates the amount reported in Other TrOOP field contains both IRASA and non-IRASA Other TrOOP
amounts.
S = indicates the amount reported in Other TrOOP field contains only IRASA Other TrOOP amount.
SPACE = indicates amount reported in Other TrOOP field contains only non-IRASA Other TrOOP amount,
if any; and for PDEs with a DOS < 01/01/2023 or for PDEs with a DOS >= 01/01/2024.
Required on PDEs with a DOS >= 01/01/2011 and a DOS <= 12/31/2024. Plan-defined benefit phase in
effect immediately prior to the time the sponsor began adjudicating the individual claim being reported.
Valid values are:
D = Deductible
N = Initial Coverage Period
G = Coverage Gap
C = Catastrophic
For PDEs with a DOS < 01/01/2011, must be SPACE. For PDEs with a DOS >= 01/01/2025, the value of G
no longer applies, and will not be accepted. Applies to covered drugs only.
Required on PDEs with a DOS >= 01/01/2011 and a DOS <= 12/31/2024. Plan-defined benefit phase in
effect upon the sponsor completing adjudication of the individual claim being reported. Valid values are:
D = Deductible
N = Initial Coverage Period
G = Coverage Gap
C = Catastrophic
For PDEs with a DOS < 01/01/2011, must be SPACE. For PDEs with a DOS >= 01/01/2025, the value of G
no longer applies, and will not be accepted. Applies to covered drugs only.
Valid values are:
1 = Written
2 = Telephone
3 = Electronic
4 = Facsimile
5 = Pharmacy
0 = Not Specified
SPACE = Unknown
For PDEs with a DOS >= 01/01/2010, only the values of 1, 2, 3, 4 or 5 are valid for the following scenarios:
1. PDEs that are standard claims (excluding Medicaid Subrogation) and Fill Number = 00
2. PACE claims with non-standard format code not in X, B, P or C and Fill Number = 00
Date sponsor received original claim. Required on PDEs with a DOS >= 01/01/2011. On PDEs with a DOS
< 01/01/2011, must be zero. Required for all LI NET PDEs submitted on and after 01/01/2011, regardless
of the DOS.
Date and time sponsor began adjudicating the claim in Greenwich Mean Time. Required on PDEs with a
DOS >= 01/01/2011. On PDEs with a DOS < 01/01/2011, must be SPACES or zero.
Plan reported value indicating whether the plan adjudicated the claim as a brand or generic drug. Valid
values are:
B = Brand
G = Generic
Required on PDEs with a DOS >= 01/01/2011. On PDEs with a DOS < 01/01/2011, must be a SPACE.
Applies to covered drugs only.
Formulary tier in which the sponsor adjudicated the claim. Required on PDEs with a DOS >= 01/01/2011.
On PDEs with a DOS >= 01/01/2022, values must be 1-7 or a SPACE.
On PDEs with a DOS >= 01/01/2011 and DOS <= 12/31/2021, values must be 1-6 or a SPACE.
On PDEs with a DOS < 01/01/2011, must be a SPACE.
Applies to covered drugs only.
Indicates if the drug is on the plan's formulary. Valid values are:
F = Formulary
N = Non-Formulary
Required on PDEs with a DOS >= 01/01/2011. On PDEs with a DOS < 01/01/2011, must be a SPACE.
Applies to covered drugs only.
Required on PDEs with a DOS >= 02/28/2013. Valid values are:
01 = Community/Retail Pharmacy Services
02 = Compounding Pharmacy Services
03 = Home Infusion Therapy Provider Services
04 = Institutional Pharmacy Services
05 = Long Term Care Pharmacy Services
06 = Mail Order Pharmacy Services
07 = Managed Care Organization Pharmacy Services
08 = Specialty Care Pharmacy Services
99 = Other
For PDEs with a DOS < 02/28/2013, valid values are SPACES or any of the valid values listed above.
For COB PDEs, valid values are SPACES or any of the valid values listed above.
Required on PDEs with a DOS >= 02/28/2013. Valid values are:
00 = Not specified, other patient residence not identified below
01 = Home
03 = Nursing Facility
04 = Assisted Living Facility
06 = Group Home
09 = Intermediate Care Facility/Intellectual Disability
11 = Hospice
For DOS < 02/28/2013, valid values are SPACES or any of the valid values listed above.
For COB PDEs, valid values are SPACES or any of the valid values listed above.
Optional on PDEs with a DOS >= 01/01/2025. Used to identify specific types of claims with the following
valid values:
SPACES
AA = 340B Claims
AB = Split Billing
AD = Nominal Price
AF = Synchronization Fill
AG = Trial Fill
For PDES with a DOS < 01/01/2025, must be SPACES.
Optional on PDEs with a DOS >= 01/01/2025. Used to identify specific types of claims with the following
valid values:
SPACES
AA = 340B Claims
AB = Split Billing
AD = Nominal Price
AF = Synchronization Fill
AG = Trial Fill
For PDES with a DOS < 01/01/2025, must be SPACES.
Optional on PDEs with a DOS >= 01/01/2025. Used to identify specific types of claims with the following
valid values:
SPACES
AA = 340B Claims
AB = Split Billing
AD = Nominal Price
AF = Synchronization Fill
AG = Trial Fill
For PDES with a DOS < 01/01/2025, must be SPACES.
Optional on PDEs with a DOS >= 01/01/2025. Used to identify specific types of claims with the following
valid values:
SPACES
AA = 340B Claims
AB = Split Billing
AD = Nominal Price
AF = Synchronization Fill
AG = Trial Fill
For PDES with a DOS < 01/01/2025, must be SPACES.
Optional on PDEs with a DOS >= 01/01/2025. Used to identify specific types of claims with the following
valid values:
SPACES
AA = 340B Claims
AB = Split Billing
AD = Nominal Price
AF = Synchronization Fill
AG = Trial Fill
For PDES with a DOS < 01/01/2025, must be SPACES.
For PDEs with a DOS >= 01/01/2025, any numeric value or SPACES may be reported in this field; if an LTCrelated value is reported, Patient Residence must be 03.
For PDEs with a DOS >= 02/28/2013 and DOS <= 12/31/2024, if Patient Residence = 03, the valid values
are:
SPACES
16 = Long Term Care (LTC) emergency box (kit) or automated dispensing machine
21 = LTC dispensing: 14 days or less not applicable
22 = LTC dispensing: 7 days
23 = LTC dispensing: 4 days
24 = LTC dispensing: 3 days
25 = LTC dispensing: 2 days
26 = LTC dispensing: 1 day
27 = LTC dispensing: 4-3 days
28 = LTC dispensing: 2-2-3 days
29 = LTC dispensing: daily and 3-day weekend
30 = LTC dispensing: Per shift dispensing
31 = LTC dispensing: Per med pass dispensing
32 = LTC dispensing: PRN on demand
33 = LTC dispensing: 7 day or less cycle not otherwise represented
34 = LTC dispensing: 14 days dispensing
35 = LTC dispensing: 8–14 day dispensing method not listed above
36 = LTC dispensing: dispensed outside short cycle, determined to be Medicare Part D after originally
submitted to another payer
For PDEs with a DOS >= 02/28/2013 and a DOS <= 12/31/2024, and with a Patient Residence Code not
equal to 03, must be SPACES. For PDEs with a DOS < 02/28/2013, must be SPACES.
For PDEs with a DOS >= 01/01/2025, any numeric value or SPACES may be reported in this field; if an LTCrelated value is reported, Patient Residence must be 03.
For PDEs with a DOS >= 02/28/2013 and DOS <= 12/31/2024, if Patient Residence = 03, the valid values
are:
SPACES
16 = Long Term Care (LTC) emergency box (kit) or automated dispensing machine
21 = LTC dispensing: 14 days or less not applicable
22 = LTC dispensing: 7 days
23 = LTC dispensing: 4 days
24 = LTC dispensing: 3 days
25 = LTC dispensing: 2 days
26 = LTC dispensing: 1 day
27 = LTC dispensing: 4-3 days
28 = LTC dispensing: 2-2-3 days
29 = LTC dispensing: daily and 3-day weekend
30 = LTC dispensing: Per shift dispensing
31 = LTC dispensing: Per med pass dispensing
32 = LTC dispensing: PRN on demand
33 = LTC dispensing: 7 day or less cycle not otherwise represented
34 = LTC dispensing: 14 days dispensing
35 = LTC dispensing: 8–14 day dispensing method not listed above
36 = LTC dispensing: dispensed outside short cycle, determined to be Medicare Part D after originally
submitted to another payer
For PDEs with a DOS >= 02/28/2013 and a DOS <= 12/31/2024, and with a Patient Residence Code not
equal to 03, must be SPACES. For PDEs with a DOS < 02/28/2013, must be SPACES.
For PDEs with a DOS >= 01/01/2025, any numeric value or SPACES may be reported in this field; if an LTCrelated value is reported, Patient Residence must be 03.
For PDEs with a DOS >= 02/28/2013 and DOS <= 12/31/2024, if Patient Residence = 03, the valid values
are:
SPACES
16 = Long Term Care (LTC) emergency box (kit) or automated dispensing machine
21 = LTC dispensing: 14 days or less not applicable
22 = LTC dispensing: 7 days
23 = LTC dispensing: 4 days
24 = LTC dispensing: 3 days
25 = LTC dispensing: 2 days
26 = LTC dispensing: 1 day
27 = LTC dispensing: 4-3 days
28 = LTC dispensing: 2-2-3 days
29 = LTC dispensing: daily and 3-day weekend
30 = LTC dispensing: Per shift dispensing
31 = LTC dispensing: Per med pass dispensing
32 = LTC dispensing: PRN on demand
33 = LTC dispensing: 7 day or less cycle not otherwise represented
34 = LTC dispensing: 14 days dispensing
35 = LTC dispensing: 8–14 day dispensing method not listed above
36 = LTC dispensing: dispensed outside short cycle, determined to be Medicare Part D after originally
submitted to another payer
For PDEs with a DOS >= 02/28/2013 and a DOS <= 12/31/2024, and with a Patient Residence Code not
equal to 03, must be SPACES. For PDEs with a DOS < 02/28/2013, must be SPACES.
For PDEs with a DOS >= 01/01/2025, any numeric value or SPACES may be reported in this field; if an LTCrelated value is reported, Patient Residence must be 03.
For PDEs with a DOS >= 02/28/2013 and DOS <= 12/31/2024, if Patient Residence = 03, the valid values
are:
SPACES
16 = Long Term Care (LTC) emergency box (kit) or automated dispensing machine
21 = LTC dispensing: 14 days or less not applicable
22 = LTC dispensing: 7 days
23 = LTC dispensing: 4 days
24 = LTC dispensing: 3 days
25 = LTC dispensing: 2 days
26 = LTC dispensing: 1 day
27 = LTC dispensing: 4-3 days
28 = LTC dispensing: 2-2-3 days
29 = LTC dispensing: daily and 3-day weekend
30 = LTC dispensing: Per shift dispensing
31 = LTC dispensing: Per med pass dispensing
32 = LTC dispensing: PRN on demand
33 = LTC dispensing: 7 day or less cycle not otherwise represented
34 = LTC dispensing: 14 days dispensing
35 = LTC dispensing: 8–14 day dispensing method not listed above
36 = LTC dispensing: dispensed outside short cycle, determined to be Medicare Part D after originally
submitted to another payer
For PDEs with a DOS >= 02/28/2013 and a DOS <= 12/31/2024, and with a Patient Residence Code not
equal to 03, must be SPACES. For PDEs with a DOS < 02/28/2013, must be SPACES.
For PDEs with a DOS >= 01/01/2025, any numeric value or SPACES may be reported in this field; if an LTCrelated value is reported, Patient Residence must be 03.
For PDEs with a DOS >= 02/28/2013 and DOS <= 12/31/2024, if Patient Residence = 03, the valid values
are:
SPACES
16 = Long Term Care (LTC) emergency box (kit) or automated dispensing machine
21 = LTC dispensing: 14 days or less not applicable
22 = LTC dispensing: 7 days
23 = LTC dispensing: 4 days
24 = LTC dispensing: 3 days
25 = LTC dispensing: 2 days
26 = LTC dispensing: 1 day
27 = LTC dispensing: 4-3 days
28 = LTC dispensing: 2-2-3 days
29 = LTC dispensing: daily and 3-day weekend
30 = LTC dispensing: Per shift dispensing
31 = LTC dispensing: Per med pass dispensing
32 = LTC dispensing: PRN on demand
33 = LTC dispensing: 7 day or less cycle not otherwise represented
34 = LTC dispensing: 14 days dispensing
35 = LTC dispensing: 8–14 day dispensing method not listed above
36 = LTC dispensing: dispensed outside short cycle, determined to be Medicare Part D after originally
submitted to another payer
For PDEs with a DOS >= 02/28/2013 and a DOS <= 12/31/2024, and with a Patient Residence Code not
equal to 03, must be SPACES. For PDEs with a DOS < 02/28/2013, must be SPACES.
For PDEs with a DOS >= 01/01/2025, used for long-term and post-acute care short-cycle (LTPAC)
dispensing. Valid values are:
SPACES
1 = Medication dispensed in a day-supply increment equal to the billed days supply (for example:
medication dispensed for a 30-day supply and billed for a 30-day supply).
2 = 7 days - dispenses medication in 7-day supplies.
3 = 4 days - dispenses medication in 4-day supplies.
4 = 3 days - dispenses medication in 3-day supplies.
5 = 2 days - dispenses medication in 2-day supplies.
6 = 1 day - dispenses medication in 1-day supplies.
7 = 4-3 days - dispenses medication in 4-day, then 3-day supplies.
8 = 2-2-3 days - dispenses medication in 2-day, then 2-day, then 3-day supplies.
9 = Daily and 3-day weekend - dispensed daily during the week and combines multiple days dispensing
for weekends.
10 = Per shift dispensing (multiple med passes).
11 = Per med pass dispensing.
12 = PRN on demand.
13 = 7-day or less cycle not otherwise represented.
14 = 14 days dispensing - dispenses medication in 14-day supplies.
15 = 8–14-Day dispensing cycle not otherwise represented.
For PDEs with a DOS < 01/01/2025, must be SPACES.
For PDEs with a DOS >= 11/13/2016 and a DOS <= 12/31/2024, the type of Adjustment Reason Code used
in field 79. Valid values are:
2 = CMS Audit
3 = CMS Identified Overpayment (CIO)
4 = CGDP Dispute or Appeal
9 = Other
SPACE = Not Applicable
The Adjustment Reason Code Qualifier of 1 has been removed from the list of valid values for PDEs with
a DOS >= 11/13/2016, and will not be accepted.
The Adjustment Reason Code Qualifiers of 3, 4, and 9 have been removed from the list of valid values for
PDEs with a DOS >= 01/01/2025, and will not be accepted.
For PDEs with a DOS >= 11/13/2016 and a DOS <= 12/31/2024, this code will assist CMS to track the
reason for an adjustment or deletion. Accepted values are dependent upon the adjustment reason code
qualifier submitted in field 78. Valid values are:
If the qualifier = 2, the valid value is: OFM, RAC, or MEDIC
If the qualifier = 3, the valid value is: CIO
If the qualifier = 4, the valid value is: DISPUTE or APPEAL
If the qualifier = 9, the valid value is: For future use at CMS' direction
If the qualifier = SPACES, the valid value is: SPACES
* Non-numeric values should be left justified
The Adjustment Reason Code Qualifier of 1 has been removed from the list of valid values for PDEs with
a DOS >= 11/13/2016, and will not be accepted.
The Adjustment Reason Codes of CIO, DISPUTE or APPEAL, and For Future use at CMS' direction have
been removed from the list of valid values for PDEs with a DOS >= 01/01/2025, and will not be accepted.
SPACES

For any field that references NCPDP values, please refer to the appropriate NCPDP specification to ensure compliance.
All dollar fields are mandatory. If the field is not applicable, report a default value of zeros. Since the field is a signed field, plans must utilize the appropriate overpunch signs as specified in the current NCPDP Telecommunications Standard.

BTR
FIELD NO.
FIELD NAME
1
RECORD ID
2
SEQUENCE NO
3
4
5
6

CONTRACT NO
PBP ID
DET RECORD TOTAL
FILLER

NCPDP FIELD

POSITION
1-3

PICTURE
X(3)

LENGTH
3

NCPDP, CMS OR PDFS DEFINED
PDFS

4 - 10

9(7)

7

PDFS

11 - 15
16 - 18
19 - 25
26 -1000

X(5)
X(3)
9(7)
X(975)

5
3
7
975

CMS
CMS
CMS
CMS

DEFINITION / VALUES
"BTR"
Must match BHD. Must start with
0000001.
Must match BHD
Must match BHD
Total count of DET records
SPACES

TLR
FIELD NO.
1
2
3
4
5
6

FIELD NAME
RECORD ID
SUBMITTER ID
FILE ID
TLR BHD RECORD TOTAL
TLR DET RECORD TOTAL
FILLER

NCPDP FIELD

POSITION
1-3
4-9
10 - 19
20 - 28
29 - 37
38 -1000

PICTURE
X(3)
X(6)
X(10)
9(9)
9(9)
X(963)

LENGTH
3
6
10
9
9
963

NCPDP, CMS OR PDFS DEFINED
PDFS
CMS
PDFS
CMS
CMS
CMS

Note:
Maximum number of detail records per file is TBD, and will be communicated in future guidance. If one file contains multiple batches,
maximum record count applies to the cumulative total across all batches.

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 0938-0982. The time required to complete
this information collection is estimated to average two (2) hours per one million (1,000,000) transactions or 0.0074 seconds per
response, including the time to review instructions, search existing data resources, gather the data 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.

DEFINITION / VALUES
"TLR"
Must match HDR
Must match HDR
Total count of BHD records
Total count of DET records
SPACES