Prior Authorization Indicator (Formulary)

SAS Name

This is a CCW-derived field that indicates whether the prescription was subject to prior authorization, according to the benefit structure and formulary for the beneficiary’s plan.


Part D plan sponsors submit the pricing, tiers, and formularies for their plan benefit packages to CMS via the Health Plan Management System (HPMS). This includes information on which drugs are subject to prior authorization, which means that a physician must get the plan’s approval in advance before prescribing the drug. The value of this field may not exactly represent the beneficiary experience at the time of the prescription fill (e.g., no data are collected at the time of the transaction to indicate the actual beneficiary experience). For 2006-2009 this variable was found in the Event Characteristics Files (BP_UM_TIER_YYYY_MM). This variable is first available in the Formulary File in 2010.

Source: CMS (HPMS Files)

Code Code value
0 No
1 Yes