Benchmark Data Layout for CY 2026 Pharmacy Cost File
Relevant to: Part D
Each week, we scan the latest CMS memos to find the most important ones that apply for PACE programs. Below is a summary of what you need to know.
Disclaimer: The content provided on this site is a summary for informational purposes only, and Grane PBM, Inc. assumes no liability for any errors or omissions in the site’s content. The information does not constitute legal or regulatory advice or replace the original CMS memo. Readers are advised to consult the CMS memo in its entirety and to verify information independently before making any decisions based on this information.
Click here to read the complete Pharmacy Cost File Layout for CY 2026.
Introduction
The Appendix D for the CY 2026 Pharmacy Cost File layout provides detailed specifications for organizing pharmacy cost data. This file includes essential fields like CONTRACT_ID, PLAN_ID, SEGMENT_ID, and PHARMACY_NUMBER, along with cost definitions such as dispensing fees and preferred status indicators. It is essential for pharmacies to understand these requirements to ensure accurate cost reporting and compliance with CMS guidelines.
Key Dates and Deadlines
- Appendix D – CY 2026 Pharmacy Cost File Layout
- May 27, 2025
PACE Compliance
This memo is relevant to PACE programs because it outlines the file layout requirements for pharmacy cost files for the Contract Year (CY) 2026, which need to be compliant with CMS protocols for proper inclusion in the Medicare Plan Finder (MPF).
Plans must ensure they use the specified structure, including unique record identifiers and specific field definitions such as CONTRACT_ID, PLAN_ID, SEGMENT_ID, and PHARMACY_NUMBER.
Details such as dispensing fees, vaccine administration fees, and preferred pharmacy status need to be correctly populated according to the guidelines outlined to avoid non-compliance. For instance, all currency fields should maintain the specified format, $$$$$$$$cccc, to be recognized correctly.
Additionally, with fields like FLOOR_PRICE, if a plan has not negotiated a floor price for pharmacy, the document mandates it to be entered as 000000000000. Missteps in this field could result in discrepancies in financial reporting and compliance issues.
Adhering to the defined ‘Yes/No’ value requirements for network status of pharmacies such as retail, mail order, LA drugs, HI (home infusion), and LTC (long term care) is crucial. Acceptable values are clearly outlined and deviations can result in the submission being non-compliant.
Ensuring compliance with these layout specifications is essential for PACE plans to maintain accurate and compliant data submissions for the upcoming CY2026. Non-compliant entries may be suppressed from being displayed in the Medicare Plan Finder (MPF), affecting participant access to necessary plan information.
Required Actions
1. Ensure all fields such as CONTRACT_ID, PLAN_ID, SEGMENT_ID, and PHARMACY_NUMBER are correctly filled out as unique identifiers in your file following CMS guidelines, including leading zeros where applicable.
2. Validate that all numerical fields, such as PREFERRED_STATUS_RETAIL, PHARMACY_RETAIL, PHARMACY_MAIL, etc., are assigned permissible values of either 0 or 1, which align with their descriptions.
3. Confirm that all currency fields follow the correct format $$$$$$$$cccc, particularly for fees and FLOOR_PRICE, ensuring non-negotiated floor pricing is represented as 000000000000 if applicable.
FAQs
- “What is the structure of the pharmacy cost file layout?”
- “How are contract, plan, and segment IDs used in pharmacy cost files?”
- “What fees are included in the CY 2026 Pharmacy Cost File for dispensing?”
- “What determines a pharmacy’s preferred status in the pharmacy cost file?”
- “How are retail, mail order, and limited access pharmacies classified in the file?”
Click here to read the complete Pharmacy Cost File Layout for CY 2026.
