News
Pharmacy Benefits and Drug Costs Reporting
April 2, 2024
April 15, 2024, is the official deadline to submit data to PAI in order for it to be included within our RxDC reporting.
Frequently Asked Questions (FAQs):
- What is the Pharmacy Benefits and Drug Costs (RxDC) report?
A provision of the Consolidated Appropriations Act (CAA) requires group health plans and health insurance issuers to report annual data to the U.S. Departments of Health and Human Services, Labor, and Treasury (Tri-Agencies) about prescription drugs and health care spending, such as employer and employee premium amounts, drug utilization, drug rebates, and spending on health care services by type (e.g. hospital, primary care, specialty care, prescription drugs, etc.).
Note: This is also called “RxDC”or the RxDC report; the “Rx” stands for prescription drug and the “DC” stands for data collection. You may also hear it called “Section 204” based on the location of the provision within the applicable part of the CAA.
- What plans does the RxDC report apply to?
RxDC Report Required RxDC Report not Required - Health insurance issuers offering group market coverage
- Health insurance issuers offering individual market coverage, including:
- Student health plans
- Plans sold through the Exchanges
- Plans sold outside of the Exchanges
- Individual coverage issued through an association
- Fully insured and self-funded group health plans, including
- Group health plans subject to Employee Retirement Income Security Act of 1974 (ERISA)
- Non-federal governmental plans, such as plans sponsored by state and local government
- Church plans that are subject to the Internal Revenue Code
- Federal Employees Health Benefits (FEHB) plans
- Account-based plans, such as health reimbursement arrangements (HRAs)
- Excepted benefits including but not limited to:
- Limited-scope standalone dental and vision plans
- Short-term limited-duration insurance
- Hospital or other fixed indemnity insurance
- Disease-specific insurance
- Medicare Advantage and Part D plans
- Medicaid plans
State children’s health insurance program plans - Basic Health Program plans
- Retirees-only plans
- Plans maintained outside of the U.S. primarily for the benefit of persons substantially all of whom are nonresident aliens
- Who is responsible for submitting this report?
Self-funded plans and health insurance issuers are responsible for this report. However, third-party administrators (TPAs), pharmacy benefit managers (PBMs), and/or other third-party vendors are permitted to submit the files to the government on behalf of self-funded plans. More than one of those entities (such as the TPA and the PBM) may submit files that make up the complete report.
- When is this report due?
Reports for a given calendar year are due by June 1 of the following year. The 2023 calendar year report is due on June 1, 2024. NOTE: Employer groups must submit 2023 data to us by April 15, 2024. This timeline is necessary to allow thorough testing of files. Please see below for more details.
- Our pharmacy benefits are carved in with OptumRx. How will our data be reported?
For carved-in groups, we will collect required pharmacy and non-pharmacy data for services we provide in-house or through a preferred vendor partner and submit the files to the Tri-agencies. We will work with OptumRx and each employer to collect data. Spending and cost data will be submitted on an aggregate base (i.e., not group specific).
- Our pharmacy benefits are carved out to an external PBM. How will our data be reported?
For carved-out groups, your PBM will be responsible for reporting the pharmacy benefit-related data on your behalf. This includes the report files D3-D8 and potentially PBM fees, which would be included in file D1. We will not submit report files D3-D8 if pharmacy benefits are administered by a carved-out PBM (A list of the report files is at the end of this FAQ).
- We carve out other services – like behavioral health, fertility, or concierge customer service. Will PAI include this in the RxDC report it submits?
PAI will offer our customers the opportunity to add carved out services that are billed or handled outside of PAI. Customers should work with their carved-out vendors to determine what amounts are appropriate to include and report to PAI within the survey. If the data is provided to PAI, and the customer attests to the completeness and accuracy of the amount(s), PAI will submit the information.
We will automatically submit data based on services we provide in-house, services where PAI handles the billing and/or through a preferred vendor partner.
- If our group terminates mid-year, will you report data for it?
Yes, we will report data for a group during the time period it was in force with us.
- If our group’s plan year begins mid-year, will you report data for it?
Yes, we will report data for a group during the time period it was in force with us.
- What data does PAI need from us, and how will you collect it?
Certain data required in the RxDC report is held by the employer. Since we will be submitting files on the employer’s behalf, we will need to collect this information from each employer annually.
Your account team will send you an email with a survey link; please use this link to respond with the relevant data as soon as possible. The deadline for receipt is April 15, 2024.
Data elements you need to provide for calendar year 2023 include:
Data Element Notes Form 5500 Plan Number If applicable, 3-digit plan number reported on the Form 5500 filed with the Department of Labor, for the group health plan(s) subject to the RxDC reporting requirements.
Does not apply to non-ERISA plans, or ERISA plans that are exempt from filing a Form 5500. Intern “N/A” if there is no Form 5500 3-digit plan number.Total Amount of all Employee Premium Collected for the Calendar Year If requested, for coverage provided or administered through us, provide the sum (in dollars) of all employee contributions towards premiums for 2023. This includes members paying COBRA premiums in 2023.
For self-funded plans, this amount generally includes all costs that are used to calculate COBRA premiums (not including the additional 2% COBRA administrative fee)d, reduced by any employer contributions and cost-sharing; stop loss reimbursements; retained drug rebases; Medicare reimbursements; carve-out vendor or benefit costs that will be separately reported; amounts related to FSA, HSA, HRA and MSA contributions, reimbursements and administration; and amounts related to an excepted benefit.
Do not include employee contributions paid separately for other health benefits, such as dental or vision.Total Amount of all Employer Premium Paid for the Calendar Year If requested, for coverage provided or administered through us, provide the sum (in dollars) of all employer contributions towards premiums in 2023.
Do not include employer contributions paid separately for other health benefits, such as dental or vision.Employer/Plan Sponsor EIN If requested, provide the plan sponsor’s IRS Employer Identification Number (EIN). - When does PAI need this data from us?
We must receive your data by April 15, 2024.
- Are you charging any fees to employers for completing this report?
No.
- There are a lot of different files required for the RxDC report. Which files will PAI be submitting?
The RxDC report is made up of 11 files designated as Plan Lists (“P” files) and Data Files (“D” files). There are three possible types of P files; plans will only be listed in one based on their market segment. There are eight D files, six of which are pharmacy specific. One P file and eight D files compose a full report; however, in some cases, for ASO groups, the PBM may be separately filing the pharmacy-specific D files. Also, a narrative response is required to describe the impact of prescription drug rebates on premium and cost sharing, among other topics.
For carved in groups, we will submit:
- P1 Individual and Student Market Plan List or P2 Group Health 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 Top 25 Drugs
- Narrative Reponses
- Where can I find more information?
You can find more information on the government’s RxDC website, located here: