Background

Group health plans are required to report various information about their prescription drug costs and spending. We’ve created a chart about the reporting requirements.

The government calls the data submission of information on prescription drug costs and spending the “RxDC report.”

The reporting deadlines are:

• December 27, 2022 for 2020 and 2021 calendar-year data
• June 1, 2023 for the 2022 calendar-year data

The government will use the data to publish reports on prescription drug costs.

The Interim Final Rule implementing the reporting provision provides that plan data may be reported to CMS in the aggregate by pharmacy benefit managers (PBMs), insurers or other reporting entities. There may also be multiple entities reporting information on behalf of a single plan.

The reporting system

Plan sponsors are required to submit their data to the government through the RxDC module in CMS’s Health Insurance Oversight System (HIOS) on the Centers for Medicare & Medicaid Services (CMS) website. HIOS is an application that is generally used by insurers. Employer-sponsored group health plans have not historically been required to use HIOS. Consequently, if plans will report their data (because their PBM is not reporting it for them) they will need to create an HIOS account at CMS’s Enterprise Portal by following the online instructions.

Plan sponsors only need one HIOS ID, even if they have multiple plan options. In addition, multiple entities may submit data to the HIOS RxDC module on behalf of a plan.

Reporting guidance

CMS has published more detailed reporting guidance along with reporting templates on its RxDC webpage, including the following:

• RxDC reporting instructions
• RxDC templates
• RxDC drug name and therapeutic class crosswalk

The RxDC reporting instructions were updated in June 2022.

The reporting templates include eight data files for:

1. Premium and life years
2. Spending by category
3. Top 50 most frequently used brand drugs
4. Top 50 most costly drugs
5. Top 50 drugs by spending increase
6. Rx totals
7. Rx rebates by therapeutic class
8. Rx rebates for the top 25 drugs

PBMs hold the data that plan sponsors will need to complete templates D3–D8. The plan or its medical administrator will have information necessary to complete templates D1–D2. Drugs covered under the pharmacy benefit should be reported in the prescription drug spending category, and drugs covered under a non-pharmacy benefit, such as hospital or medical, should be reported in the hospital or medical spending category.

An additional template (P2) contains identifying information for the plan.

Finally, a narrative response is required in word or PDF to describe answers to additional questions posed by the government.

Action items

Segal can assist plan sponsors to determine how their PBMs are submitting data, what health data needs to be submitted and how to obtain a HIOS ID.