Prescription Drug and Claims Summary Data

DUE by December 27, 2022
Among the CAA’s many new compliance requirements for health plans is a significant reporting obligation that is “sneaking up” on the industry. The reports, called the RxDC (Prescription Drug Data Collection) reports, need to be filed by all group health plans, including governmental plans and church plans. Two reports are due on December 27, 2022, the reports on the 2020 and 2021 calendar years. After that, reports are due by June 1 annually.
TPAs and PBMs will be primarily responsible for producing the data needed for these reports. Still, plan sponsors are responsible for ensuring that the appropriate data is reported to CMS.

WHAT DATA NEEDS TO BE REPORTED?

The RxDC reports need to contain the following categories of data (organized by type):

PLAN DEMOGRAPHIC INFORMATION

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Group Health Plan Name & Number

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Plan Sponsor Name & EIN

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Issuer or TPA Name & EIN

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PBM Name & EIN

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Market Segment (e.g., fully insured small group,self-funded large group, etc.)

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HIOS Plan ID & Plan Name

PBM DATA

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Top 50 Most Frequent Brand Drugs

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Top 50 Most Costly Drugs

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Top 50 Drugs by Spending Increase

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Rx Totals

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Rx Rebates by Therapeutic Class

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Rx Rebates for the Top 25 Drugs

TPA DATA

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Total Premiums

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Number of Covered Lives

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Spending in each of the following categories:

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Hospital

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Primary Care

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Specialty Care

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Other medical costs and services

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Known medical benefit drugs

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Estimated medical benefit drugs

NARRATIVE RESPONSES

Written responses are required to a set of specific questions. One example is: Did you use actual counts or estimate to determinethe size of the employer for self-funded plans? Describe yourestimation method if you used estimates.

CMS anticipates the data needed will be submitted in “aggregate” form—i.e., plan-level reporting is not required. However, plan sponsors must ensure that all required elements are filed on behalf of their plan. This isn’t an easy task. Putting together the pieces of an RxDC report involves a massive coordination of data effort.

Download MZQ’s Deep Dive: RxDC Reporting Guide.

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MZQ Consulting, LLC is not a law firm and cannot dispense legal advice. Anything contained in this communication is not and should not be construedas legal advice. If you need legal advice, please contact your legal counsel.

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