Medicare Part D Event file: Utilization Management Variables

Formulary linkage and Variable Differences between 2006-09 and 2010-forward files

Medicare Part D Event file: Utilization Management Variables

Current Version Date: 
08/10/2012

The Medicare Part D Event data file for 2006-0099 includes four variables referred to as the "Utilization Management" (UM) variables.  These variables include prior authorization, quantity limit, tier and step therapy.  Beginning with the CY2010 PDE, these four variables are part of the PDE Formulary Characteristics file.

Part D data 2006-09 formulary linkage

Each of these variables has the option to be flagged "NA" or "XX", assigned when one or another type of link could not be made between the PDE record and plan information.  (Please see the CCW PDE data dictionary for the variable specifics.)

Linkage was attempted by matching the PDE record’s contract ID and plan ID to information for each formulary ID.  The PDE record’s NDC code was matched to a brand name/generic product ID, using the proprietary database from First Data Bank (FDB).  If a match existed between formulary ID and the brand/generic ID, the Utilization Management variables in the PDE could be populated.

If a linkage could not be made between the PDE record’s plan identifiers and the CMS Health Plan Management System (HPMS) formulary data, the flag of “XX” was assigned for the UM variables and a Formulary ID could not be assigned.  The HPMS data available to the CCW at the time the PDE 2006-09 files were processed was a year-end snapshot.  Prior to 2010, terminated plans weren't maintained in the system.  So if a plan dropped during the year, the match could not be made.

"NA" was the value most often assigned to the unlinked cases.  These occur because the NDC from the PDE record did not match a drug on the plan's formulary.  This happened for several reasons.

If the NDC on the PDE was for a generic drug product and if the Part D plan submits a particular branded version that has a different brand name than the FDB drug data base that CCW uses, then the drugs were not linked and the UM variables were flagged “NA”.

A second possible cause for the inability to link the NDCs was related again to the file the CCW uses to create the PDE data, the HPMS.  That system includes only one occurrence of a plan's formulary, from the end of the year.  Since plans can change their formulary over the course of a year, a PDE record can include an NDC that is no longer included in the formulary.

Part D data 2010-forward formulary linkage

Beginning with the 2010 data, two new variables appear in the PDE data, the Encrypted Formulary ID (FORMULARY_ID) and the Formulary RX ID (FRMLRY_RX_ID).  The four UM variables, prior authorization, quantity limit, tier and step therapy, have been moved to a Part D Characteristics file introduced with the 2010 data.

Researchers will link the PDE record to the Formulary file record based on the Formulary RX ID.

The “XX” and “NA” flags are no longer used.  Since the HPMS system now included terminated plans, the lack of match on plan identifiers no longer occurs.  That means there would no longer be any reason for this flag.

When the linkage can’t be made, the Formulary_RX_ID will be blank.  The “NA” flag will no longer be used.

Inability to link the PDE NDC to a formulary drug can happen for various reasons: changes to the formulary during the year (CCW works with the HPMS year-end snapshot that does not document formulary changes), the generic/brand name combination does not match any in the FDB, the PDE NDC does not match any NDC in the FDB (rare occurrence).

Additional Resources: 
AttachmentSize
CCW Part D Data User Guide333.75 KB
Acknowledgments: 
ResDAC is grateful to staff of Buccaneer, a General Dynamics Company, for their assistance with the topic of this article.
Article Number: 
152
Author(s): 
This work was performed under CMS Contract Number HHSM-500-2005-00027I.
Related Data File Families: 

Disclaimer

The process and materials mentioned as part of this KnowledgeBase article are current, as of the publication date on the article, to the best of our knowledge. The examples provided are correct in the aggregate but may not apply to every subgroup or circumstance that a researcher may wish to study. It is up to the researcher to conduct analysis and confirm that the patterns described in this KnowledgeBase article apply to his/her particular study. If your research findings appear to contradict the advice provided, please contact ResDAC at resdac@umn.edu.