Pharmacy Benefits and Cost Reporting
Under the Consolidated Appropriations Act (CAA), health insurers offering group or individual health coverage and self-funded (ASO) group health plans are required to report data annually regarding prescription drugs and health care spending to the Departments of Health and Human Services, Labor, and Treasury (Tri-Agencies). This information must be submitted through a web portal that is being set up by the Centers for Medicare & Medicaid Services (CMS).
The Dec. 27, 2021, report date had a delayed enforcement until Dec. 27, 2022. After the reporting, the December reports will be required by June 1, each year.
The report includes general information identifying the insurer or plan as follows:
- Enrollment and premium information, including average monthly premiums paid by employees and the employer
- Total health care spending, broken down by type of cost (e.g., hospital care, primary care, specialty care, prescription drugs, and other medical costs including wellness services) by enrollees and by employer or insurer
- Prescription drug spending by enrollees and employers or insurer
- 50 most frequently dispensed brand prescription drugs
- 50 costliest prescription drugs by total annual spending
- 50 prescription drugs with the greatest increase in plan or coverage expenditures from the prior year
- Prescription drug rebates, fees, and other remuneration paid by drug manufacturers to the plan or issuer in each therapeutic class of drugs, as well as for each of the 25 drugs that yielded the highest amount of rebates
- Impact of prescription drug rebates, fees, and other remuneration paid by prescription drug manufacturers on premiums and out-of-pocket costs
Reporting will be aggregated at the state/market level, rather than separately for each plan. The guidance provides uniform standards and definitions, including standards for identifying prescription drugs regardless of the dosage strength, package size, or mode of delivery. There are uniform standards for submitting data are intended to allow the Tri-Agencies and U.S. Office of Personnel Management (OPM) to conduct meaningful data analysis and identify prescription drug trends.
- Fully Insured: UnitedHealthcare will submit the report and required data for all fully insured. We will not accept requests for fully insured customers to submit the data themselves.
- Self-funded: There are two standard and one additional approach for submitting data for ASO customers. Refer to the CAA UHC ASO Approach Pharmacy Benefits and Costs Reporting Guide
- UnitedHealthcare submits all data for Level Funded and UMR submits all data
- UnitedHealthcare and the customer share responsibility to submit specific data
- Self-funded customers may produce the report and submit the data to CMS themselves.
If PBM, wellness and/or stop loss provider is another services provider, the self-funded customer must ensure the other service provider submits the appropriate files.