Aug. 12, 2022

Approach to Required Prescription Drug Cost Reporting

Applies to all groups

What it is: The Consolidated Appropriations Act, 2021 requirement for Pharmacy Benefit and Drug Cost Reporting was deferred until Dec. 27, 2022. Reporting for the 2020 and 2021 plan years is required on that date.
 

• Insurance companies and employer-based health plans must submit information about prescription drugs and health care spending to Centers for Medicare & Medicaid Services (CMS).
   
• This data will be used to identify major drivers of cost increases and understand impacts on premiums and out-of-pocket costs.
   
• This is being done to help promote transparency in prescription drug pricing.

What’s new: With recent guidance  from regulators, Blue Cross and Blue Shield of Texas (BCBSTX) can now share how we will support our clients with the reporting requirement.

Background: CMS requires eight data files and the applicable plan list to be included in Pharmacy Cost Reporting. The amount of information we have available, and level of support we can provide groups, will vary based on funding type and Pharmacy Benefit Manager (PBM).

Fully Insured Groups:

• BCBSTX will submit the required plan list and data files for Fully Insured groups. Groups don’t need to take any action at this time. We will communicate if additional information is needed from them.

ASO groups with Prime:

• For groups with Prime Therapeutics^® as their PBM, BCBSTX will work with Prime to submit the P2 plan list and D2 through D8 data files. All ASO groups will need to submit the D1 (Premium and Life Years) data directly to CMS through the RxDC module in the Health Insurance Oversight System (HIOS).
   
• If you have questions or feedback about this approach, please contact your BCBSTX representative.

ASO groups with a carve-out pharmacy benefit:

• BCBSTX will only submit the D2 data (spending by category) and P2 plan list (group health plan list) to the CMS website for ASO groups with a carved-out pharmacy benefit. All other required data will need to be submitted to CMS through the RxDC module in HIOS by the group or their vendors.

What’s next: More implementation details will be shared later this year as they become available.

Prime Therapeutics LLC is a separate pharmacy benefit management company contracted by Blue Cross and Blue Shield of Texas (BCBSTX) to provide pharmacy benefit management and related other services. BCBSTX, as well as several independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime Therapeutics.