By: Kaitlyn MacLeod, Esq.

Our consultants have been receiving tons of questions in the last month about the upcoming Prescription Drug and Health Care Spending reporting (RxDC) requirements. The first two reports are due on December 27, 2022, for the 2020 and 2021 calendar years.

Referring to this requirement as the Prescription Drug Data Collection is a misnomer – a lot of the required elements are related to health care spending, not prescription drug costs – which is a surprise to many. Be sure that you know what data you need to provide to stay in compliance. Outside of the Rx data, CMS is requesting the following:

• Plan Information (FEIN, # of Participants/Beneficiaries/Enrollees and the States in Which They Reside, and Plan Year)
• Total Annual Spending on Health Care Services, Broken Down by Type of Cost:
  • Hospital
  • Health Care Provider and Clinical Service Costs – Primary Care and Specialty Care
  • Costs for Medical Prescription Drugs, and
  • Other Medical Costs, Including Wellness Programs.
• Monthly Premium Payments Paid by Employers and Participants/Beneficiaries/Enrollees

In addition to the above, the RxDC requirements do require specific reporting on Prescription Drug spending, including:

• Top 50 Drug Lists – Most Frequent Brand Drugs Dispensed
• Top 50 Most Costly Prescription Drugs
• Top 50 Prescription Drugs With Greatest Increase in Plan Expenses That Year
• Total Annual Spending by the Plan
• Total Annual Spending by the Participants, Beneficiaries, and Enrollees in the Plan
• The Number of Participants and Beneficiaries With a Paid Prescription Drug Claim
• Total Dosage Units Dispensed and
• The Number of Paid Claims.

Typically, a plan may receive this information through its TPA or PBM. TPAs should consider updating their ASAs to explicitly provide what data, if any, they are reporting on behalf of the plan to meet the RxDC requirements.

There is a common misconception that only PBMs need to fill out the required information – it is ultimately the plan’s responsibility to ensure compliance. Even if a plan contracts with their vendors like TPAs and PBMs to provide part of the data, the plan will still be responsible for ensuring that all of the data is submitted.

What should plans do now?

1. Sign up for your account with CMS soon, it can take over a week to get set up.
2. Check in with your TPA and PBMs to set up written agreements to provide the reporting data.
3. Understand what data, if any, is left to the plan to provide.
4. Upload the reports by December 27, 2022.

Do you have questions about the RxDC Reporting Requirements? We are here to help, contact us at pgcreferral@phiagroup.com

.