CMS-10715-Transparency in Coverage_Appendix 4_

OMB Control No. 0938-1372
Expiration Date: XX/XX/XXXX

APPENDIX 4:
Prescription Drug Machine-Readable File
Data Elements
The Departments of the Treasury, Labor, and Health and Human Services (the Departments)
have issued the Transparency in Coverage final rules (85 FR 72158), which require nongrandfathered group health plans and health insurance issuers in the individual and group
markets (plans and issuers) to disclose certain pricing information. Under the final rules at 26
CFR 54.9815-2715A3(b), 29 CFR 2590.715-2715A3(b), and 45 CFR 147.212(b), a plan or
issuer must disclose in-network drug prices through a machine-readable file posted on an internet
website. In-network drug prices include both “negotiated rates” and “historical net prices” as
defined at 26 CFR 54.9815-2715A1, 29 CFR 2590.715-2715A1, and 45 CFR 147.210. The table
below identifies data elements that a plan or issuer is required to include in each machinereadable Prescription Drug File. 1
DATA ELEMENT

DESCRIPTION

General Information

Blank

Name of Reporting Entity 2

The legal name of the entity publishing the machinereadable file.

Type of Entity

The type of entity that is publishing the machinereadable file (a group of health plan, health insurance
issuer, or a third party with which the plan or issuer has
contracted to provide the required information, such as
a third-party administrator, a health care claims
clearinghouse, or a health insurance issuer that has
contracted with a group health plan sponsor).

For more technical implementation guidance for this machine-readable file, please see the GitHub website space
established by the Departments. GitHub is a website and cloud-based service that helps developers store and manage
their code, as well as to track and control changes to their code. The GitHub space offers the Departments the
opportunity to collaborate with industry, including regulated entities, and third-party developers to ensure the file
format is adapted for reporting of the required public disclosure data for various plan and contracting models. The
GitHub space is available at: https://github.com/CMSgov/price-transparency-guide.
2
A plan or issuer may contract with a third party (such as a third-party administrator, a health care claims
clearinghouse, or a health insurance issuer that has contracted with a group health plan sponsor) to satisfy the
disclosure requirements, subject to the requirements in the final rules.
1

DATA ELEMENT

DESCRIPTION

Date of Last File Update

The date the machine-readable file was last updated.

Identification of Plan or
Coverage

Blank

Plan or Coverage Name

The plan name and name of plan sponsor and/or
insurance company (for example, “Maximum Health
Plan: Alpha Insurance Group”).

Plan Identifier

The 10-digit Health Insurance Oversight System
(HIOS) identifier, or, if the 10-digit HIOS identifier is
not available, the 5-digit HIOS identifier, or if no HIOS
identifier is available, the Employer Identification
Number (EIN), for each coverage option offered by a
plan or issuer.

Type of Plan Identifier

EIN or HIOS IDs, as applicable.

Type of Plan Market

The type of market in which the plan is offered
(individual or group market coverage).

Identification of Providers,
Pharmacies, and Place of Service

Individual Provider Identifier

Blank

The National Provider Identifier (NPI) Type 1 3 - The
unique 10-digit identification number issued to a
provider by the Centers for Medicare & Medicaid
Services (CMS) to identify induvial health care
providers.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/NPIWhat-You-Need-To-Know.pdf

3

DATA ELEMENT
Provider Group and Pharmacy
Identifier (Required if the innetwork provider is a group
organization or pharmacy)

Pharmacy Identifier (Plans and
issuers have the option to include
these elements in addition to the
NPI Type 2)

DESCRIPTION
The NPI Type 2 4 - The unique 10-digit identification
number issued to a provider by CMS for an
organization of health care providers, such as a medical
group or pharmacy.
The National Council for Prescription Drug Programs
(NCPDP) ID 5 - The unique 7-digit number assigned by
the NCPDP to every licensed pharmacy and nonPharmacy Dispensing Site (NPDS) in the United States
and its territories. This number represents a unique
pharmacy entity or line of business and is used to
identify licensed pharmacies and NPDSs to insurance
companies, health care providers, and other entities.
The NCPDP Chain Code 6 - The ID number provided
by the NCPDP that represents a group of pharmacies
under the same ownership.
If the plan or issuer includes the NCPDP Chain Code,
it must also include the NCPDP IDs for each pharmacy
that is represented in the group of pharmacies that are
identified by the NCPDP Chain Code.
Allowed values: “NCPDP ID,” “NCPDP Chain Code,”
or “NPI.”
“NPI” must be selected to indicate NPI-type 2
pharmacy identifiers.

Type of Pharmacy Identifier

“NCPDP ID” must be selected to indicate NCPDP ID
pharmacy identifiers.
“NCPDP Chain Code” must be selected to indicate
NCPDP chain code pharmacy identifiers.

4

Ibid.
https://www.resdac.org/cms-data/variables/ncpdp-pharmacy-identifier-pharmacy-characteristics
6
https://accessonline.ncpdp.org/Resources/Help/NCPDP%20Part%202%20Training%20Guide%20v1.04.pdf
5

DATA ELEMENT

Tax Identification Number (TIN)

Plan of Service Code 7

Drug Pricing Information

DESCRIPTION
The unique identification number issued either by the
Social Security Administration or by the Internal
Revenue Service (IRS).
The CMS-maintained two-digit code that is placed on a
professional claim, to indicate the setting in which a
service was provided.
Blank

Drug Name/ Plain Language
Description

The proprietary and nonproprietary name assigned to
the National Drug Code (NDC) by the Food and Drug
Administration (FDA).

Type of Drug

“Branded,” “Generic,” or “Biosimilar.”
A unique 10-digit or 11-digit, 3-segment number
assigned by the FDA, which provides a universal
product identifier for drugs in the United States.

National Drug Code (NDC)

Historical Net Price

Data reporting will be on the first 8 digits of the full
10-digit or 11-digit NDCs. The last 2 digits of the full
10-digit or 11-digit NDC specify quantity and do not
have an impact on the negotiated rate or historic net
price.
The retrospective average amount paid, reflected as a
dollar amount, by a plan or issuer to an in-network
provider for the 90-day period beginning 180 days
before the file publication date, including any innetwork pharmacy or other prescription drug dispenser,
for a prescription drug, inclusive of any reasonably
allocated rebates, discounts, chargebacks, fees, and any
additional price concessions received by the plan or

“Place of Service Code Set.” CMS. Available at: https://www.cms.gov/Medicare/Coding/place-of-servicecodes/Place_of_Service_Code_Set.
7

DATA ELEMENT

DESCRIPTION
issuer with respect to the prescription drug or
prescription drug service.
The historic net price must be reported at the billing
unit level as defined by the NCPDP. The standard
contains three units: Each “EA,” Milliliter “ML,” or
Gram “GM.” 8
Notes on reasonable allocation of rebates, discounts,
chargebacks, feeds, and any additional price
concessions received by the plan or issuer:
•

If the total amount of the price concession is known
to the plan or issuer on the file publication date,
then rebates, discounts, chargebacks, fees, and
other price concessions must be reasonably
allocated by total known dollar amount.

•

If the total amount of the price concession is not
known to the plan or issuer on the file publication
date, then rebates, discounts, chargebacks, fees, and
other price concessions should be reasonably
allocated using a good faith, reasonable estimate of
the average price concessions based on the rebates,
discounts, chargebacks, fees, and other price
concessions received over a time period prior to the
current reporting period and of equal duration to the
current reporting period.

Historical Net Price

Historical Net Price Allocation
Reporting Period

If the historical net price concessions are not known to
the plan or issuer on the last publication date on the
file, then the time period prior to the current reporting
period used for reporting purposes must be displayed.

Negotiated Rate for each Covered
Prescription Drug

The amount, reflected as a dollar amount, that a plan or
issuer has contractually agreed to pay an in-network
provider, including an in-network pharmacy or other
prescription drug dispenser, whether directly or
indirectly, including through a third-party administrator

NCPDP Billing Unit Standard Fact Sheet found here:
https://www.ncpdp.org/NCPDP/media/pdf/BUS_fact_sheet.pdf.

8

DATA ELEMENT

Negotiated Rate for each Covered
Prescription Drug

DESCRIPTION
or pharmacy benefit manager, for prescription drugs.
The negotiated rate must be reported at the billing unit
level as defined by NCPDP. The standard contains
three units: “EA,” “ML,” or “GM.”
Fees that are assessed at the point of sale must be
reflected separately as a dollar amount (see Dispensing
Fee, Administrative Fee, and Transaction Fee data
elements).

Dispensing Fee

The fee, reflected as a dollar amount, for dispensing a
prescription applied at the point of sale. The fee must
be reflected separately only for the negotiated rate data
element.

Administrative Fee

The fee, reflected as a dollar amount, charged by the
Pharmacy Benefit Manager to the plan or issuer for
administrating each prescription. This fee must be
reflected separately only for the negotiated rate date
element.

Transaction Fee

Any fees, reflected as a dollar amount, assessed when
processing a prescription that is not associated with the
administrative or dispensing fee. This fee must be
reflected separately only for the negotiated rate data
element.

Paperwork Reduction Act Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a
collection of information unless it displays a valid Office of Management and Budget (OMB)
control number. The Departments are seeking OMB approval for the model as part of the
approval for a new OMB control number 0938-1372. The time required to complete this
information collection is estimated to average 1,031 hours per respondent, including the time to
review instructions, search existing data resources, gather the data needed, and complete and
review the information collection. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security
Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland
21244-1850.