high prescription drugs with money and stethoscope

As a requirement of the Consolidated Appropriations Act of 2021 (CAA), group health plans and carriers must be prepared to submit information about prescription drug spending by December 27, 2022.

U.S. Departments of the Treasury, Labor, and Health and Human Services (the Departments) plan to use this information to issue public reports on prescription drug pricing, costs, and trends in 2023.

Prescription Drug Cost Reporting Requirements

Group health plan sponsors must submit the following information to the Departments regarding drug costs:

  • General information regarding the plan or coverage
  • Enrollment and premium information, including average monthly premiums paid by employees
  • Total healthcare spending, broken down by type of cost (hospital, primary care, specialty care, prescription drugs, and other medical costs)
  • Prescription drug spending by enrollees versus employers and issuers
  • The 50 most frequently dispensed brand prescription drugs and the total number of paid claims for each drug
  • The 50 costliest prescription drugs by total annual spending, as well as the amount spent by the plan for each drug
  • The 50 prescription drugs with the greatest increase in plan or coverage expenditures from the previous 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
  • The impact of prescription drug rebates, fees, and other remuneration on premiums and out-of-pocket costs

What Self-Insured Employers Should be Doing

It’s highly unlikely that self-insured employers would have everything above readily available to them. As a result, self-insured employers should be working with their benefits advisors, health plans, TPAs, and PBMs now to ensure compliance. The TPA and/or PBM should have the necessary information to fulfill the requirements on the employer’s behalf. But remember, regardless of any agreement with the TPA or PBM, self-insured employers are ultimately liable for compliance. So, it’s particularly important that there are employer protections in the TPA/PBM contract in the case of compliance failure.

Prescription Drug Cost Reporting Resources

Prescription Drug and Health Care Spending Interim Final Rule
CMS FAQ
Consolidated Appropriations Act of 2021

Please note: The information provided in this blog post is a high-level discussion of the Prescription Drug Cost Reporting Requirements. Please speak with your benefits advisor, TPA, PBM, and/or legal counsel to learn how these requirements will affect your organization.

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SentryHealth is leading the charge in employee health and wellbeing. Integrating smart technology with personalized guidance from Registered Nurse Advocates, we empower employees to make more informed decisions while guiding them to quality, affordable care. The result is greater engagement, higher satisfaction, better outcomes, and lower costs.