CY 2026 Pricing File Layout Guide: Key Fields and Descriptions
Relevant to: Drug Pricing, Part D
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Click here to access the complete Pricing File Layout for CY 2026.
Introduction
The CY 2026 Pricing File Layout is an essential guide for healthcare organizations that outlines the structure of pricing files critical for compliance. This appendix includes unique record identifiers such as CONTRACT_ID, PRICE_ID, NDC, DAYS_SUPPLY, and IS_MAIL, ensuring comprehensive data organization. By understanding these components, organizations can effectively manage and navigate their contract pricing strategies with accuracy.
Key Dates and Deadlines
- May 27, 2025
PACE Compliance
The CY 2026 pricing file layout as outlined in Appendix F is crucial for ensuring compliance with PACE programs. The data fields and their correct formatting play a key role in meeting regulatory requirements. Here’s how each component affects PACE compliance:
CONTRACT_ID: It is imperative that the CONTRACT_ID is used correctly as it identifies the organization’s contract number assigned by CMS. Incorrect references can lead to compliance issues as it serves as the primary identifier.
PRICE_ID: This identifier must be unique to each pricing group. Failure to properly assign PRICE_IDs could result in incorrect pricing information submissions.
NDC: The specified 11-digit National Drug Code (NDC) correctly identifies the drug/dose form combination from the approved formulary. Non-compliance with this specification may lead to incorrect drug listing or submissions in the PACE program.
DAYS_SUPPLY: Ensure the DAYS_SUPPLY field is correctly populated with the values 30, 60, or 90. If inaccurate data is submitted, it may not only result in compliance issues but also affect medication availability for beneficiaries.
IS_MAIL: This field indicates if the price applies to a network contracted mail order pharmacy (0 for retail, 1 for mail order). Compliance depends on correctly identifying the dispensing context, which can affect cost management and reporting.
UNIT_COST: The unit cost reflects pricing up to the point-of-sale rebate. Precise calculation of UNIT_COST is essential for accurate pricing representation and compliance. Misrepresentation can lead to significant discrepancies in the PACE program’s cost reporting.
HAS_CEILING_COST: Indicates if a ceiling price is applicable (0 for no, 1 for yes). Proper indication of ceiling prices is necessary for compliance, and any errors can lead to financial inaccuracies affecting PACE calculations.
Therefore, adherence to the pricing file layout’s structure and parameters is key for compliance with PACE regulations, and organizations should carefully manage and verify these attributes to ensure accurate submissions.
Required Actions
1. Ensure all fields in the pricing file are filled out correctly without leaving any required fields NULL. Double-check the formats such as the CONTRACT_ID being a Char(5) and the NDC being a Char(11).
2. Verify that the DAYS_SUPPLY field is populated with one of the acceptable values: 30, 60, or 90, and that IS_MAIL and HAS_CEILING_COST fields only contain values 0 or 1 to indicate the correct cost applicability.
3. If your organization applies rebates at the point-of-sale, confirm that these are appropriately applied up to the full value of the UNIT_COST without affecting the dispensing fee.
FAQs
- “What are the unique record identifiers in the CY 2026 Pricing File Layout?”
- “How is the UNIT_COST calculated in the Pricing File?”
- “What is the significance of the HAS_CEILING_COST field in the Pricing File?”
- “How are NDC codes used in the CY 2026 Pricing File?”
- “What do the different values of IS_MAIL indicate?”
Click here to access the complete Pricing File Layout for CY 2026.
