In an era where transparency in healthcare costs is more crucial than ever, RxDC Reporting stands out as a pivotal regulatory requirement that aims to shed light on the complexities of prescription drug pricing. Introduced by the Consolidated Appropriations Act (CAA) of 2021, this mandate requires group health plans and health insurance issuers to disclose detailed information about the prescription drugs they cover and the associated costs. While this requirement offers opportunity for improved public policy, it also creates burden and risk for employers resulting from annual disclosure requirements.
Valhalla Business Advisors is committed to equipping clients with the expertise and tools necessary to navigate the requirements under RxDC. Understanding the scope of the mandate, the specific data required, and the implications of compliance are essential for maintaining regulatory adherence and optimizing health plan operations
What is rxdc?
RxDC Reporting, or Prescription Drug Data Collection Reporting, was established by the Consolidated Appropriations Act (CAA) of 2021. This regulation serves as a crucial component of a broader initiative aimed at enhancing transparency within the healthcare sector, particularly concerning prescription drugs. It mandates that group health plans and health insurance issuers providing group or individual health insurance coverage meticulously report detailed information about the prescription drugs they cover and the associated costs. This initiative not only seeks to shed light on prescription drug pricing but also aims to facilitate better healthcare cost management.
What are the obligations of employers?
The RxDC Reporting requirements extend to a wide range of plan sponsors, encompassing:
- Fully insured, small group plans
- Fully insured, large group plans
- Self-funded (including Level funded), small group plans
- Self-funded (including Level funded), large group plans
It is important to note that there are very few exceptions for reporting; There is no exception for churches or governments; There is no exception for small business.
These stipulations ensure that a broad spectrum of health plans contribute to the transparency and data collection efforts, providing a comprehensive view of the drug pricing landscape across various types of health insurance arrangements.
What data is necessary? Where does data come from?
The information necessary for effective reporting encompasses various aspects of health plan operations and drug pricing strategies. This data is categorized and collected primarily through two specific forms known as the Plan (P) and Drug (D) forms.
- Plan and Drug Information Forms (P and D Forms):
- Plan Form (P): This form collects general information about the health plan, including plan year, types of benefits offered, and the number of plan participants. It serves as a foundational document that outlines the scope and coverage specifics of the health plan.
- Drug Form (D): Focused on the pharmaceutical aspect, this form requires detailed data on prescription drugs covered by the plan, including usage statistics, cost data, and pricing arrangements. It’s instrumental in analyzing the financial impact of drug coverage under the health plan.
- Data from Insurers or Third-Party Administrators (TPAs):
- Insurers and TPAs play a crucial role in the healthcare ecosystem by managing health claims and overseeing the administration of benefits. For RxDC Reporting, they provide essential data on claims, including the volume of transactions, reimbursement rates, and total expenditure on prescribed medications. This data helps in understanding the broader financial implications of drug benefits on health plans.
- Information from Pharmacy Benefit Managers (PBMs):
- PBMs are at the forefront of managing prescription drug benefits and are critical in the negotiation of drug prices and rebates. The information they provide includes detailed pricing structures, rebate agreements, and cost management strategies employed throughout the plan year. This data is vital for assessing the effectiveness of cost-control measures and the overall affordability of drug coverage.
What is new for 2025?
For the year 2025, there are notable updates to the RxDC Reporting requirements that plan sponsors need to be aware of:
- Revised guidelines for premium equivalent calculations, ensuring more standardized reporting.
- Stricter aggregation restrictions to enhance data accuracy and integrity.
- Carrier-specific changes in reporting methods and employer responsibilities.
What are the implications for employers? Is there financial liability?
For employers, the implications of RxDC Reporting are significant, both in terms of administrative responsibility and potential financial liability. Employers need to ensure accurate and timely submission of required information to avoid penalties. While there is no direct financial penalty articulated in the statute, failure to comply with reporting requirements can lead to financial penalties arising from ERISA (e.g. $100 per participant per day). Furthermore, the administrative burden of gathering and reporting this data requires adequate resources and systems, potentially leading to increased operational costs.
The Valhalla advantage
At Valhalla Business Advisors, we understand the complexities and challenges associated with RxDC Reporting. Our expertise in navigating these regulatory waters ensures that our clients can fulfill their reporting obligations without undue stress or error. We offer tailored support to manage compliance efficiently, ensuring that all data is accurate, comprehensive, and submitted on time. Let Valhalla Business Advisors be your guide in the intricate landscape of healthcare reporting, where our strategic insights and solutions keep your operations smooth and compliant.
APPENDIX
| Carrier | Fully Insured Reporting | Self/Level-Funded Reporting | Employer Surveys | Resources & Submission Links |
|---|---|---|---|---|
| Aetna | Prescription Drug Data Collection (RxDC) reporting for reference year 2024 is required to be submitted no later than June 1, 2025. Aetna will email plan sponsors starting January 31, 2025, requesting the following data: total premium paid by members, total premium paid by employer, funding arrangement, and issuer name/legal entity. | Self-funded plan sponsors may request to be excluded from Aetna’s D1 file; if so, they do not need to complete the data collection process. Instead, they must contact their account representative to request an exception. | Required survey due by March 31, 2025. Failure to respond will result in Aetna submitting the report without plan sponsor data, potentially leading to non-compliance risks. | 2025 Aetna Prescription Drug Data (RxDC) Collection Requirement How to Complete the Aetna.com RxDC Plan Sponsor Data Collection Form Overview CMS Reporting Instructions |
| Capital BlueCross | Capital Blue Cross will submit the required plan list and data files for fully insured groups. Employers are required to report the MEMBER average monthly premium, which should also be included in Premium Equivalents. | For ASO groups, Capital Blue Cross will submit the required plan list and data files. Employers are required to report the MEMBER average monthly premium, which should also be included in Premium Equivalents. Also, they should report ASO fees paid and stop loss premium paid. | Submit the survey by March 31, 2025 for your appropriate funding (“ASO Small Business or Fully Insured” or “ASO”) through the link once logged on to the Capital BlueCross website. | Capital BlueCross Survey Link (Login Required) |
| Highmark Blue Shield | Highmark needs the employer/member premium data due no later than April 14, 2025. | Self-insured (ASO) plans must submit premium equivalents, ASO fees, stop-loss premiums, and monthly premiums for 2024 by April 14, 2025, at 11:59 PM EST. ASO clients with carved-out pharmacy benefits must submit pharmacy data directly to CMS via PBMs. | Submit via RxDC survey by April 14, 2025. Self-insured (ASO): Submit premium equivalents, ASO fees, stop-loss premiums, and monthly premiums for 2024. ASO clients with carved-out pharmacy benefits must submit pharmacy data directly to CMS via PBMs. | Highmark Producer Blast RxDC Highmark RxDC Survey |
| UnitedHealthcare / United Oxford | UnitedHealthcare will submit P2, D1, and D2 files for all active employers in 2024. Employers must complete the RFI tool between February 3, 2025 – March 31, 2025. | Self-funded plans must complete the RFI tool if using UHC for reporting; otherwise, they must coordinate D3-D8 submissions with their PBM. Employers using outside PBMs, including OptumRx direct, must coordinate their own data submission. | Required RFI or survey due by March 31, 2025. Failure to respond may result in incomplete CMS submission. Customers who offer both Surest and UHC may need to complete separate RFIs on Employer E-services and uhcEservices. | 2025 UnitedHealthcare/Oxford Approach to CAA Prescription Drug (RxDC) Reporting RxDC Guide UHC RxDC FAQs (info on CMS RxDC requirements and a how-to submit data to UHC) |
| BlueCross BlueShield of Texas | BCBSTX will submit the required plan list and data files for fully insured groups with Prime Therapeutics as PBM, Blue Balance FundedSM groups, and Minimum Premium plans. | For ASO and Cost Plus groups with Prime Therapeutics as PBM, BCBSTX will work with Prime to submit the P2 plan list and D2 through D8 data files. All group customers need to submit the D1 (Premium and Life Years) data directly to CMS through the RxDC module. | Survey is accessed on https://www.bcbstx.com/ Details on data collection will be sent via email to group contacts beginning the week of March 18, 2025 due by April 26, 2025. BCBS collects the average premium paid by the employer and members inside the employer’s Blue Access for Employers account. The form requests the figures as total monthly averages (total annual contributions divided by 12, even if the group’s coverage lasted less than 12 months). The survey may be completed by the employer or broker. | 2023 Prescription Drug Data Collection (RxDC) Group Reporting Approach Sample Screenshots |
| Florida Blue | For Fully Insured, the choices are PPO – Florida Blue, HMO – Health Options or HMO – Truli. Fully insured employer groups will need to provide the following information: Total premium paid by the EMPLOYEE AND total premium paid by the EMPLOYER from the 2024 Calendar Year, and Department of Labor Form 5500 Plan Number. Premium amounts should be in the 000.00 format. | For ASO/Self-Insured the choices are PPO – Florida Blue, HMO – Health Options or HMO – Truli. Self-insured employer groups will need to provide the following information: Total premium paid by the EMPLOYEE, total premium paid by the EMPLOYER from the 2024 Calendar Year, average total number of employees including seasonal and part-time, Department of Labor Form 5500 Plan Number, and Pharmacy Benefit Manager name (if with another provider). Premium amounts should be in the 000.00 format. | They created three distinct surveys tailored to your specific group type: Fully Insured, MPP, and ASO/Self-Insured groups. You will receive an email with a unique link to access your designated survey. The survey will contain pre-populated information that we ask you to review and confirm. If any information is incorrect, you will have the opportunity to update it with the correct details. The survey is due by March 15, 2025.Per 2023 info, In an effort to make sure all data is collected, Florida Blue has opened an outbound call center. Affected groups will receive phone calls between March 1 and April 15, 2023, and brokers will also receive an email requesting their assistance with these groups. | 2025 Florida Blue RxDC Step-By-Step Survey Instructions Instruction to Complete the Consolidated Appropriations Act (CAA) Section 204 Pharmacy Reporting |
| CDPHP | CDPHP needs the following information: Group health plan name and employer identification number (EIN), market segment for their group (small or large group market), the average monthly premium amount paid by members, and the average monthly premium amount paid by employers.If the data questionnaire is not completed by the deadline, the responsibility will fall on the employer group to submit the average monthly premium amount paid by members and paid by employers for fully insured groups. | CDPHP needs the following information: Group health plan name and employer identification number (EIN), the average monthly premium amount paid by members, the average monthly premium amount paid by employers, life years, premium equivalents, ASO/TPA fees paid, and stop loss premium paid.If the data questionnaire is not completed by the deadline, the responsibility will fall on the employer group. Self-funded groups will be responsible for submitting the D1 report. | Survey sent via email to brokers and groups with instructions on how to complete. It is due by April 14, 2025. | CDPHP Survey Link for Fully Insured CDPHP Survey Link for Self-Funded CDPHP Assistance with Average Monthly Premium Amount Paid by Members vs. by Employers CMS RxDC Reporting Instructions |
| UPMC | At this time, we do anticipate that subsequent submissions will require groups to affirmatively provide information to UPMC Health Plan (for example, the portion of premium amounts paid by employer v. member). Additional details about how and when that information must be provided to UPMC Health Plan will be forthcoming. | At this time, we do anticipate that subsequent submissions will require groups to affirmatively provide information to UPMC Health Plan (for example, the portion of premium amounts paid by employer v. member). Additional details about how and when that information must be provided to UPMC Health Plan will be forthcoming. | Likely WILL be a survey required. More information forthcoming for UPMC. | UPMC RxDC Information & FAQ |
Additional Resources
Sources
2025 Changes: https://www.cms.gov/files/document/january2025updatestothedrugdataprocessingg.pdf
Reporting Instructions: https://www.cms.gov/marketplace/about/oversight/other-insurance-protections/prescription-drug-data-collection-rxdc#:~:text=RxDC%20reporting%20instructions%20(PDF)
Sample Scope of Work
