According to CMS, RxDC Reporting is intended to enhance transparency and shed light on how prescription drugs contribute to the growth of healthcare spending and the cost of health coverage.* To answer your questions, we’ve prepared the following FAQ.
What is RxDC Reporting?
RxDC Reporting (also called Pharmacy Benefit and Drug Costs Reporting) is federally required reporting from the Consolidated Appropriations Act (CAA), 2021. Section 204 requires group health plans and health insurance issuers offering group, individual, and self-funded health insurance coverage, as well as student health plans, to submit information about prescription drugs and healthcare spending to the Department of Health and Human Services (HHS), the Department of Labor (DOL), and the Department of the Treasury. In addition, the Director of the Office of Personnel Management (OPM) requires Federal Employees Health Benefits (FEHB) carriers to submit Section 204 data to HHS. The Centers for Medicare & Medicaid Services (CMS) collects Section 204 data submissions on behalf of these departments and OPM.
When is reporting due?
The first report is due December 27, 2022. Subsequent reports are due June 1 every year after. The first submission is for reference years 2020 (containing 2019 and 2020 data) and 2021 (2020 and 2021 data). PacificSource is currently on track to meet both deadlines.
What data range and type of information is needed for the reference year?
For the 2020 reference year, if with CVS Caremark for the entire year, data for 2019 will be reported. Similarly, for the 2021 reference year, data for 2020 will be reported.
The information includes:
- P1 Individual and Student Market Plan List
- P2 Group Health Plan List
- P3 FEHB Plan List D1 Premium and Life Years
- D2 Spending by Category
- D3 Top 50 Most Frequent Brand Drugs
- D4 Top 50 Most Costly Drugs
- D5 Top 50 Drugs by Spending Increase
- D6 Rx Totals
- D7 Rx Rebates by Therapeutic Class
- D8 Rx Rebates for the Top 25 Drugs
- Narrative Response File
What market segments must be included?
The market segments are:
- Individual market
- Student market
- Fully-insured small group market
- Fully-insured large group market (excluding the FEHB line of business)
- Self-funded group health plans offered by small employers
- Self-funded group health plans offered by large employers
- FEHB line of business
Who is responsible for gathering and submitting this information?
PacificSource will compile all elements for P1-D2.
CVS will submit all elements for D3-D8. CVS will also compile the following:
- Drugs missing from the CMS crosswalk
- Prescription drug rebate descriptions
- Allocation methods for prescription drug rebates,
- Impact of prescription drug rebates for the narrative file where PacificSource will be summitting elements
- Employer size for self-funded plans
- Wellness services
- Drugs covered under hospital or medical benefits
PacificSource and CVS are each responsible for submitting their own assigned elements, as well as their assigned elements from the Narrative Response File. All elements will be validated by PacificSource to ensure accuracy.
Are there costs associated with RxDC reporting and submission?
Yes. PacificSource will cover the associated costs for the RxDC reporting for our fully insured business segments, as well as our self-funded clients that have our integrated Pharmacy Benefit Management (PBM) solution.
What if a client uses a PBM other than PacificSource/CVS?
Clients who use a third party to administer their pharmacy benefits should work with their PBM to obtain required data files for D3-D8 and the elements in the Narrative Response File required by the PBM.
PacificSource will compile elements for P1-D2. However, the third party PBM will need to file on behalf of the plan sponsor, or the plan sponsor/consultant will need to coordinate the filing. Groups who use CVS PBM through a contract not with PacificSource will need to coordinate with the plan sponsor/consultant for filing.
What if a client used a different third-party administrator during the required reference year?
Clients should work with their prior insurance carrier and PBM to obtain required data files for the time not with PacificSource.
Note: This information is subject to change as more information and guidance become available.
*Source: “Prescription Drug and Health Care Spending Interim Final Rule with Request for Comments,” CMS.gov