Group Health Plan Name & Number
Plan Sponsor Name & EIN
Issuer or TPA Name & EIN
PBM Name & EIN
Market Segment (e.g., fully insured small group,self-funded large group, etc.)
HIOS Plan ID & Plan Name
Top 50 Most Frequent Brand Drugs
Top 50 Most Costly Drugs
Top 50 Drugs by Spending Increase
Rx Totals
Rx Rebates by Therapeutic Class
Rx Rebates for the Top 25 Drugs
Total Premiums
Number of Covered Lives
Spending in each of the following categories:
Hospital
Primary Care
Specialty Care
Other medical costs and services
Known medical benefit drugs
Estimated medical benefit drugs
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.
