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 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 | Aetna will email plan sponsors starting February 2, 2026, requesting the following data: – Total premium paid by members from the 2025 Calendar Year- Total premium paid by employer from the 2025 Calendar Year- Funding arrangement, and issuer name/legal entity. | Aetna will email plan sponsors starting February 2, 2026, requesting the following data: – Total premium paid by members from the 2025 Calendar Year- Total premium paid by employer from the 2025 Calendar Year- Funding arrangement, and issuer name/legal entity. Note: 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. | The required survey is due by March 31, 2026. Failure to respond will result in Aetna submitting the report without plan sponsor data, potentially leading to non-compliance risks. | Aetna RxDC Reporting Instructions How to Complete the Aetna.com RxDC Plan Sponsor Data Collection Form |
| Capital BlueCross | For fully insured groups, Capital needs groups to fill out the “CAA – RxDC reporting form” under the Employers tab of the online portal.Employers are required to report the average MEMBER monthly premium for the 2025 Calendar Year. | For small business ASO Groups (<100 employees), Capital can submit D1 data if you opt in; complete the “CAA – RxDC reporting form” under the Employers tab. Note: Compliance with RxDC D1 requirements remains your responsibility. On the survey, report average member monthly premium, ASO/TPA fees, stop-loss premiums, and premium equivalents for 2025.For Large ASO Groups (≥100 employees) and Consortium groups (<100 employees), they may file directly with the federal government; filing through Capital is optional. If filing through Capital, complete the “CAA – RxDC reporting form”. Report the same data as small business ASO groups.For groups with both large ASO AND small business ASO or a fully insured plan in 2025, they must complete the form twice, once for the large ASO period and once for the small ASO/fully insured period.Groups with a separate PBM for pharmacy benefits should work with the PBM to report D3-D8 pharmacy data. | The required survey is due by March 27, 2026. Please select 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) |
| Geisinger | For fully insured Geisinger groups: NO action is required. Geisinger will file on your behalf. | For ASO, ACA, and KYP groups, and Geisinger GFA plans, a survey IS required: – Log into the Geisinger Employer Portal – Navigate to Plan Administration – Select “No Surprises Act – Prescription Drug Data Collection” – Complete the requested information | For ASO, ACA, and KYP groups and Geisinger GFA groups, the required survey is due by April 30, 2026. Failure to respond may result in incomplete CMS submission. | Geisinger RxDC Reporting Instructions |
| Highmark | Highmark requires average monthly premiums paid by the employer and by members for the 2025 Calendar Year. | Self-insured (ASO) plans must submit premium equivalents, ASO and TPA fees, stop-loss premiums, and average monthly premiums paid by the employer and by members for the 2025 Calendar Year. ASO clients WITH carved-out pharmacy benefits must submit pharmacy data directly to CMS via their Pharmacy Benefit Manager. Highmark will NOT submit this data to CMS. | The required survey is due by April 17, 2026, at 11:59 PM EST. Failure to respond may result in incomplete CMS submission. You may use the survey link here to begin: Highmark RxDC SurveyHighmark will contact clients stressing the deadline with brokers providing support as needed. | Highmark RxDC Reporting Instructions Highmark RxDC Reporting Summary Highmark RxDC Survey |
| UnitedHealthcare | UnitedHealthcare will submit P2, D1, and D2 files (and required narratives) for all fully insured groups active during 2025.If the group uses OptumRx integrated (carve-in) PBM, UHC will also submit D3-D8 pharmacy files.Employers must complete the RxDC Request for Information (RFI) on the UHC or All Savers employer portal as it’s available now. | Level-funded and self-insured employers 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 and must coordinate directly with the PBM to ensure required pharmacy files are submitted.Note: UMR groups receive a separate RFI link from their UMR Strategic Account Executive. | Required RFI form is due by March 31, 2026. The RFI is available now via the portal. Failure to respond may result in incomplete CMS submission. Customers who offer both Surest and UHC may need to complete separate RFIs. | UnitedHealthcare RxDC Reporting Guide Video of RxDC Reporting Guide UnitedHealthcare RxDC FAQs (Info on CMS RxDC requirements and a how-to submit data to UHC) Additional Guide to Reporting UnitedHealthcare RxDC Summary UnitedHealthcare RxDC Reminder Summary |
| 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: – Total premium paid (in dollars) by the EMPLOYEE – Total premium paid (in dollars) by the EMPLOYER from the 2025 Calendar Year | For ASO/Self-Insured the choices are PPO – Florida Blue, HMO – Health Options or HMO – Truli. Self-insured employer groups with NO pharmacy carveout will need to provide the following: – Total premium paid (in dollars) by the EMPLOYEE – Total premium paid (in dollars) by the EMPLOYER from the 2025 Calendar YearSelf-insured employer groups WITH pharmacy carveout will need to provide the following: – Pharmacy Benefit Manager name (if with another provider). – PBM Tax ID – Average total number of employees including seasonal and part-time in 2025 – Department of Labor Form 5500 Plan Number (ASO only) – Total premium equivalents and administrative feeds paid by the EMPLOYEE in 2025 Calendar Year (for both health & pharmacy) – Total premium equivalents and administrative feeds paid by the EMPLOYER in 2025 Calendar Year (for both health & pharmacy)- Total ASO/TPA fees paid (in dollars) in 2025 Calendar Year (for pharmacy)- Total premium equivalents paid (in dollars) 2025 Calendar Year (for pharmacy) | Surveys are issued by group type: Fully Insured, MPP, and ASO/Self-Insured groups. You will receive either a mailed letter or an email with a link to access your designated survey. The survey will contain pre-populated information for your review, with the opportunity to correct. The required survey is due by March 15, 2026. Failure to respond may result in incomplete CMS submission. | Florida Blue RxDC Reporting Instructions Florida Blue RxDC Step-By-Step Survey Instructions Instruction to Complete the Consolidated Appropriations Act (CAA) Section 204 Pharmacy Reporting |
| CDPHP | An email was sent out to brokers and clients with instructions in February. CDPHP needs the following information for fully insured groups: 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.Note: 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. | An email was sent out to brokers and clients with instructions in February. CDPHP needs the following information for self-funded groups: 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. | The required survey is due by April 15, 2026. | 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 | An email with a form was sent out to the group contact on file. There are different forms for fully insured, SALF groups, etc. The form is only being accepted when it is completed through the Docusign one sent out. UPMC Health Plan will automatically submit required RxDC data to CMS on behalf of groups, including files P1, P2, P3 and D1-D8, assuming UPMC administers all.The submission will include required medical spend detail and prescription drug cost information to the extent UPMC administers such coverage for the employer group. With the exception of member premium amounts, UPMC will not collect or report information not currently in its possession or that is handled by another third-party vendor, insurer, or pharmacy benefit manager. | An email with a form was sent out to the group contact on file. There are different forms for fully insured, SALF groups, etc. The form is only being accepted when it is completed through the Docusign one sent out.UPMC Health Plan will automatically submit required RxDC data to CMS on behalf of groups, including files P1, P2, P3 and D1-D8, assuming UPMC administers all.The submission will include required medical spend detail and prescription drug cost information to the extent UPMC administers such coverage for the employer group. With the exception of member premium amounts, UPMC will not collect or report information not currently in its possession or that is handled by another third-party vendor, insurer, or pharmacy benefit manager. | The required survey is due by March 31, 2026. | UPMC RxDC Reporting Instructions UPMC RxDC Information & FAQ |
| Veris / Benecon (Self-Funded Consortium Groups) | For consortium or Benecon self-funded groups:- Employers are responsible for coordinating between their ASO/TPA, PBM, and other vendors.- Benecon provides data typically used for the D1 portion of the filing.- Many ASO partners impose deadlines earlier than the federal June 1 filing deadline. |
Additional Resources
Sources
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
