CMS-R-262 CY 2026 Prior Authorization File Record Layout

CY 2026 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

PA Change Type

CHAR

Maximum
Field
Length
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 2024, 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 offlabel 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 2026 Prior Authorization File Record Layout
Field Name

Field Type

Off-label Uses

CHAR
Required
only if a 4 is
entered for
PA
Indication
Indicator

Exclusion Criteria

CHAR

Maximum
Field
Length
3000

Enter the specific off-label uses for which the PA will be
approved. This field must not contain any FDA-approved
indications.

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

Field Description

If
applicable
Part B Prerequisite

CHAR
If
applicable

1

If the PA criteria requires a Part B drug before a Part D drug
then please enter “1” in this field”, otherwise enter “0”. This
field only applies to MAPD plans that are associated with this
formulary ID.

Prerequisite Therapy Required

CHAR

1

If the PA criteria requires use of a prerequisite Part D drug
then please enter “1” in this field, otherwise enter “0”.

Always
Required

Please Note: Certain characters are restricted from HPMS. The submitted file will be rejected if it contains restricted
characters in any field, such as: 1) greater than sign (>), 2) less than sign (<), 3) semi-colon (;), 4) ampersand and hash
combination (&#), etc.

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