Issuers and FEHB Carriers

OMB control number: 0938-1407
Expiration Date: MM/DD/YYYY

Department of Health & Human Services
Centers for Medicare & Medicaid Services
7500 Security Boulevard, Mail Stop 00-00-00
Baltimore, Maryland 21244-1850

Prescription Drug Data Collection
(RxDC) Reporting Instructions
Section 204 Data Submission Instructions
for the 2020 and 2021 Reference Years
Updated June 28, 2022

Paperwork Reduction Act Statement
According to the Paperwork Reduction Act of 1995 (PRA), 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 valid OMB control number for this information collection is 0938-1407. The time required
to complete this information collection is estimated to average 4,731 hours per response, 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.

Table of Contents
Changes from the November 2021 version of the RxDC Instructions .......................................................... 4
1

2

3

4

5

Overview ............................................................................................................................................... 5
1.1

What is the RxDC report? ............................................................................................................. 5

1.2

Who must submit the RxDC report? ............................................................................................. 5

1.3

When is the deadline? .................................................................................................................. 6

1.4

Where can I get help? ................................................................................................................... 6

Required Files........................................................................................................................................ 6
2.1

Plan Lists and Data Files ................................................................................................................ 7

2.2

Narrative Response ....................................................................................................................... 7

Submission Process ............................................................................................................................... 8
3.1

Where do I submit my data?......................................................................................................... 8

3.2

Can a vendor submit information on my behalf? ......................................................................... 8

3.3

Can multiple vendors submit my data? ........................................................................................ 8

3.4

What if a vendor can’t fill out an entire file? ................................................................................ 9

3.5

What if a plan changes vendors during the reference year? ........................................................ 9

3.6

How do I know if a reporting entity submitted my data?............................................................. 9

Plan List Definitions............................................................................................................................... 9
4.1

General Definitions ..................................................................................................................... 10

4.2

HIOS Definitions .......................................................................................................................... 12

4.3

Group Definitions ........................................................................................................................ 13

4.4

FEHB Definitions.......................................................................................................................... 14

Data Aggregation ................................................................................................................................ 15
5.1

Market Segment Aggregation ..................................................................................................... 15

5.2

State Aggregation........................................................................................................................ 16

5.3

Issuer and TPA Aggregation ........................................................................................................ 17

5.4

Examples of Aggregate Reporting............................................................................................... 18

6

Premium and Life-Years ...................................................................................................................... 20

7

Spending ............................................................................................................................................. 23

8

7.1

Definitions ................................................................................................................................... 24

7.2

Spending Categories ................................................................................................................... 25

Prescription Drug Reporting ............................................................................................................... 30
8.1

Prescription Drug Coverage ........................................................................................................ 30

2

9

8.2

Drug Aggregation ........................................................................................................................ 30

8.3

Rx Utilization ............................................................................................................................... 33

8.4

Rx Spending ................................................................................................................................. 34

8.5

Top Drug Lists .............................................................................................................................. 36

Rebates, Fees, and Other Remuneration ............................................................................................ 39
9.1

Definitions ................................................................................................................................... 39

9.2

Allocation Methods ..................................................................................................................... 42

10 Narrative Response ............................................................................................................................. 43
11 Appendix A: File Layouts for the RxDC Report .................................................................................... 45
11.1

Plan Lists...................................................................................................................................... 45

11.2

Data Files ..................................................................................................................................... 51

11.3

File Requirements ....................................................................................................................... 60

3

Changes from the November 2021 version of the RxDC Instructions
The RxDC reporting instructions have been updated in response to:
•
•

Public comments on the Paperwork Reduction Act package (CMS-10788) related to the interim
final rules titled Prescription Drug and Health Care Spending (86 FR 66662), published on
November 23rd, 2021
Help desk inquiries sent to CMS at [email protected]

The most significant changes to the RxDC reporting instructions include the following:
Plan Lists
• Added definitions for the columns in the plan list files
• Clarified the treatment of non-calendar year plans
• Added columns to the plan list files for reporting entities to indicate which plans are included in
the data files
Spending Categories
• Moved the spending category for drugs covered under a medical benefit (medical benefit drugs)
from data file D6 Rx Totals to data file D2 Spending by Category
• Eliminated the spending category in D2 for pharmacy benefit drugs
• Combined the spending categories for wellness services and other medical costs and services
• Required that spending on wellness services be restricted to claims-based costs
• Differentiated spending on medical benefit drugs according to whether the drug was separately
billed or included as part of a bundled payment arrangement
• Provided additional detail on classifying claims according to spending category
Total Spending
• Specified the circumstances when manufacturer cost-sharing assistance must be subtracted
from total spending
• Provided guidance on allocating net payments from any federal or state reinsurance or costsharing reduction arrangement or program
Average Monthly Premium Paid by Members and by Employers
• Clarified how to calculate the average monthly premium
• Changed the term “employee” to “member” in the instructions for calculating average premium
per member per months
• Updated instructions with respect to 2020 and 2021 reference year reporting
Prescription Drugs
• Clarified that authorized generics and branded generics are treated as generic drugs for RxDC
reporting
• Updated examples to include the RxDC drug codes

4

1 Overview
1.1 What is the RxDC report?
In these instructions, the term RxDC report refers to the data submission required under Section 204 of
Division BB, Title II (Section 204) of the Consolidated Appropriations Act, 2021 (CAA). 1 The Rx stands for
Prescription Drug and the DC stands for Data Collection.
Section 204 requires group health plans (plans) and health insurance issuers (issuers) offering group or
individual health insurance coverage to submit information about prescription drugs and health care
spending to the Department of Health and Human Services (HHS), the Department of Labor (DOL), and
the Department of the Treasury (the Departments). In addition, the Director of the Office of Personnel
Management (OPM) requires Federal Employees Health Benefits carriers (carriers) to submit Section
204 data to HHS. The Centers for Medicare & Medicaid Services (CMS) is collecting Section 204 data
submissions on behalf of the Departments and OPM.
The implementing regulations for the Section 204 data collection are at 5 CFR part 890, 26 CFR part 54,
29 CFR part 2590, and 45 CFR part 149.

1.2 Who must submit the RxDC report?
Required to Submit
• Health insurance issuers offering group coverage
• Health insurance issuers offering individual market
coverage, including:
o Student health plans
o Plans sold through the Exchanges
o Plans sold outside of the Exchanges
o Individual coverage issued through an
association
• Fully-insured and self-funded group health plans,
including:
o Non-federal governmental plans, such as plans
sponsored by state and local government
o Church plans that are subject to the Internal
Revenue Code
o Federal Employees Health Benefits (FEHB) plans

Not Required to Submit
• Account-based plans, such as health
reimbursement arrangements
• Excepted benefits 2 including but not
limited to:
o Short-term limited-duration
insurance
o Hospital or other fixed indemnity
insurance
o Disease-specific insurance
• Medicare Advantage and
Part D plans
• Medicaid plans
• State children’s health insurance
program plans
• Basic Health Program plans

These requirements apply regardless of whether a plan is considered a grandfathered or grandmothered
health plan. 3
The CAA is available at https://www.congress.gov/116/bills/hr133/BILLS-116hr133enr.pdf. Section 204 Section
204 of Division BB, Title II starts on page H. R. 133—1737.
2
PHS Act 2722(b) and (c), ERISA Section 732, and Code Section 9831.
3
Grandmothered plans, sometimes referred to as transitional plans, are non-grandfathered plans in the individual
and small group market that were issued prior to January 1, 2014, and for which CMS announced it will not take
enforcement action with respect to certain market requirements. See Bulletin: Extended Non-Enforcement of
Affordable Care Act-Compliance With Respect to Certain Policies, available at
https://www.cms.gov/files/document/extension-limited-non-enforcement-policy-through-calendar-year-2022.pdf.
1

5

Plans, issuers, and carriers may have vendors submit the RxDC report on their behalf. See Section 3 for
more information about vendor submissions.

1.3 When is the deadline?
The last day to submit your data for the 2020 and 2021 reference years is December 27, 2022. 4 The
deadline for subsequent reference years is June 1st of the calendar year immediately following the
reference year. A reference year is the calendar year of the data that is in your RxDC report. For
example, the RxDC report for the 2020 reference year means the information in the report is based on
what happened in 2020.
What is a Reference Year?
The reference year is the calendar year of the data that is in your RxDC report. For example, the RxDC
report for the 2020 reference year means the information in the report is based on what happened in
2020.

1.4 Where can I get help?
You can find more information about RxDC reporting on the CMS website at
https://www.cms.gov/CCIIO/Programs-and-Initiatives/Other-Insurance-Protections/Prescription-DrugData-Collection. You can also sign up for email announcements and register for training webinars at
Registration for Technical Assistance Portal (REGTAP) at https://regtap.cms.gov/rxdc.php.
If you can’t find the answer to your question in REGTAP, contact our help desk at 1-855-267-1515 or
[email protected]. Include “RxDC” in the body of the email for faster service. You can typically
expect a response within the same day and a full resolution within 1-2 weeks.
REGTAP
Sign up for announcements and training webinars at Registration for Technical Assistance Portal
(REGTAP): https://regtap.cms.gov/rxdc.php
Help Desk
Contact our help desk at 1-855-267-1515 or [email protected]. Include “RxDC” in the body of
the email for faster service. You can typically expect a response within the same day and a full
resolution within 1-2 weeks.

2 Required Files
Plans, issuers, and carriers must submit one or more plan lists (P1-P3), eight data files (D1-D8), and a
narrative response.

The statutory deadlines to submit the RxDC report for the 2020 and 2021 reference years are December 27, 2021
and June 1, 2022, respectively. However, the Departments are deferring enforcement for the 2020 and 2021
reference years if you submit your data by December 27, 2022. See FAQs About Affordable Care Act and
Consolidated Appropriations Act, 2021 Part 49, Q12, available at https://www.cms.gov/CCIIO/Resources/FactSheets-and-FAQs/Downloads/FAQs-Part-49.pdf and https://www.dol.gov/sites/dolgov/files/EBSA/about-ebsa/ouractivities/resource-center/faqs/aca-part-49.pdf.
4

6

2.1 Plan Lists and Data Files
Subject
File Names

Plan Lists
P stands for Plan
• P1 Individual and student market plan
list
• P2 Group health plan list
• P3 FEHB plan list

Purpose

The plan lists identify the plans in a
submission. The plan lists also collect planlevel information required by statute, such
as the beginning and end dates of the plan
year, the number of members, and the
states in which the plan or coverage is
offered.
Requirement • P1 is required for plans in the individual
or student market
• P2 is required for employer-based
health plans that are not FEHB plans
• P3 is required for FEHB plans
File Format
Comma Separated Values (CSV)

Data Files
D stands for Data
• D1 Premium and Life-Years
• D2 Spending by Category
• D3 Top 50 Most Frequent Brand
Drugs
• D4 Top 50 Most Costly Drugs
• D5 Top 50 Drugs by Spending
Increase
• D6 Rx Totals
• D7 Rx Rebates by Therapeutic Class
• D8 Rx Rebates for the Top 25 Drugs
The data files collect premium and
spending information at an aggregate
level.

All 8 data files are required.

Comma Separated Values (CSV)

The file layouts for the plan lists and data files are in Appendix A of these instructions. The plan list and
data file templates are on the CMS website at https://www.cms.gov/CCIIO/Programs-andInitiatives/Other-Insurance-Protections/Prescription-Drug-Data-Collection.

2.2 Narrative Response
A narrative response is required. Describe the impact of prescription drug rebates on premium and cost
sharing in the narrative response. You must also respond regarding the other topics described
throughout these instructions. The narrative response file format must be Portable Document Format
(.pdf) or Microsoft Word (.doc or .docx). See Section 10 for more information on the narrative response.

Optional Supplemental Documents

If you want to provide additional information about your submission, the system will allow you to
upload supplemental PDF or Word documents. This is optional.

7

3 Submission Process
3.1 Where do I submit my data?
Submit your data through the RxDC module in the Health Insurance Oversight System (HIOS). To log in
to HIOS, go to the CMS Enterprise Portal at https://portal.cms.gov/portal/.
Do I need to create a CMS Enterprise Portal or HIOS Account?
You do NOT need to create a CMS Enterprise Portal or HIOS account if:
• You already have a HIOS account, or
• You are not uploading any files (because an issuer, third-party administrator, pharmacy
benefit manager, or other reporting entity is uploading files on your behalf).
NOTE: It can take up to two weeks to create your accounts. Don’t wait until the last minute!
The instructions to create your CMS Enterprise Portal and HIOS accounts are in the HIOS Portal User
Manual. The instructions for using the RxDC module are in the RxDC HIOS User Manual.

3.2 Can a vendor submit information on my behalf?
Yes. Plans, issuers, and carriers can contract with issuers, third-party administrators (TPAs), Pharmacy
Benefit Managers (PBMs), or other third-party vendors to submit data on their behalf. An entity that
submits some or all required information is called a reporting entity. In these instructions, “you”
generally refers to the reporting entity.
What is a reporting entity?
An entity that submits some or all required information is called a reporting entity. In these
instructions, “you” generally refers to the reporting entity.

3.3 Can multiple vendors submit my data?
Yes. A plan, issuer, or carrier can allow multiple reporting entities to submit on its behalf. For example, a
self-funded group health plan may contract with a TPA to submit the Spending by Category data file (D2)
and separately contract with a PBM to submit the Top 50 Most Costly Drugs file (D4). The submission for
a plan, issuer, or carrier is considered complete if CMS receives all required files, regardless of who
submits the files.
Multiple reporting entities should not submit the same data file for a plan, issuer, or carrier. For
example, a TPA and PBM should not both submit D2 for the same group health plan. The HIOS system
does not automatically prevent duplicate submissions of the same file. CMS will check whether there are
duplicate files after the submission deadline.
Each reporting entity must submit one or more plan list files (P1, P2, and/or P3). That is how CMS will
know when multiple entities are reporting for the same plan. If you know which reporting entity will also
be reporting on behalf of a plan, enter its company name and Employer Identification Number (EIN) in
the appropriate columns in the plan list file. CMS will use this information to streamline the
reconciliation process when there are multiple reporting entities.

8

Note: It’s not a problem if multiple reporting entities upload different narrative responses on behalf of
the same plan, issuer, or carrier.
To preserve confidentiality, a reporting entity can view only the files that it uploads. It cannot view files
uploaded by a different reporting entity even if the information is related to the same plan, issuer, or
carrier. For example, if a TPA uploads D2 and a PBM uploads D4 for the same group health plan, the TPA
can see only D2 and the PBM can see only D4. The group health plan cannot see either D2 or D4. The
plan should contact its reporting entities directly if the plan wants to see the data uploaded on its
behalf.

3.4 What if a vendor can’t fill out an entire file?
Plans, issuers, carriers, and their reporting entities must work together so that each data file submitted
in HIOS contains all required information. If one reporting entity is responsible for only some of the
fields in a data file, it should fill out those fields and then give the data file to the other reporting entity
to complete the remaining information before submitting the data file in HIOS. 5

3.5 What if a plan changes vendors during the reference year?
If a plan, issuer, or carrier changes vendors during the reference year (such as changing a TPA or PBM),
there are two reporting options:
•
•

The previous vendor reports the data from earlier in the year and the new vendor reports the
data from later in the year; or
The previous vendor provides the data to the new vendor and the new vendor reports the
entire year of data

Either way, the plan sponsor must ensure that all their data is reported and that it is not doublereported.

3.6 How do I know if a reporting entity submitted my data?
Currently, CMS does not have a mechanism to notify plans, issuers, or carriers when data has been
submitted on their behalf. To confirm submission, plans, issuers, and carriers should contact their
reporting entities directly.

4 Plan List Definitions
Use the following definitions when you fill out your plan lists.
Note 1: Do not uses slashes (“/”) in alphanumeric fields. HIOS won’t accept text with slashes because
data with slashes requires additional security screening that would slow down processing time. The
exception is that you can use slashes in the column headers and in date fields.
Note 2: You may use commas in in alphanumeric fields if the string is enclosed by double-quotation
marks as text qualifiers. (Ex: “Mary’s Hardware Store, Inc.”) The double-quotation marks are necessary
so that HIOS can differentiate from commas used as delimiters and commas used in a text string.

If there are extenuating circumstances that prevent vendors from working together, contact the help desk at
[email protected]. CMS will get back to you to discuss the situation.

5

9

4.1 General Definitions
Members as of 12/31
Location: P1, P2, P3 | Max decimal places: 0 | Must not be blank
Enter the number of members as of 12/31 of the reference year. You must enter a whole number
without decimal places. If a plan year ended before 12/31 of the reference year, enter 0.
What is a Member?
For the purposes of these instructions, the term “member” means a person who has health coverage,
regardless of whether the coverage is associated with an insurance policy, a group health plan, or an
FEHB plan. For example, enrollees, dependents, participants, beneficiaries, and FEHB annuitants are
all considered members.

Plan Year Beginning and End Dates
Location: P1, P2, P3 | Format: MM/DD/YYYY | Must not be blank
Enter the plan year beginning and end dates.
Individual and Student Markets
Generally, you may enter the first and last day of the reference year. For grandfathered and
grandmothered individual market plans, you may alternatively enter the date on which the plan was
first offered, and the date on which the plan was closed to new enrollment. For student health plans,
you may alternatively enter the plan or policy year, or if the year is not designated in the plan or policy
document, then the deductible or limit year used under the coverage.
Group Markets
Enter the actual beginning and end dates of the plan year, even if they fall outside of the reference year.
For example, if the plan year is July 1, 2019 through June 30, 2020, enter 07/01/2019 for the beginning
date and 06/30/2020 for the end date in the 2020 RxDC report. Since the plan year ended before the
end of the reference year, enter 0 for the number of members as of 12/31/2020 in the 2020 RxDC
report.
Similarly, if the plan year is July 1, 2020 through June 30, 2021, enter 07/01/2020 for the beginning date
and 06/30/2021 for the end date in the 2020 RxDC report. Enter the actual number of members as of
12/31/2020 in the 2020 RxDC report.
If a plan renews in the middle of the reference year, use two rows in the plan list file: one row for the
plan year that ended on 6/30/2020 and another for the plan year that began on 7/1/2020.
Example: Non-calendar year plan in the 2020 RxDC report.
Group
Plan Year
Group Health Plan
Market
Health Plan
Beginning
Name
Segment
Number
Pate
Jane’s Furniture
Small group
07/01/2019
Health and Welfare
501
market
Plan

Plan Year
End Date

Members as of
12/31 of the
reference year

06/30/2020

0

10

Group Health Plan
Name
Jane’s Furniture
Health and Welfare
Plan

Group
Health Plan
Number

Market
Segment

Plan Year
Beginning
Pate

Plan Year
End Date

Members as of
12/31 of the
reference year

501

Small group
market

07/01/2020

06/30/2021

27

Note: In the data files (as opposed to the plan lists), the reporting entity would include only the data
related to the 2020 calendar year (e.g. the last six months of the “old” plan and the first six months of
the “new” plan).

Market Segment
Location: P1, D1-D8 | Max length 100 characters | Must not be blank
Location: P2 | Max length 512 characters | Must not be blank
The following table has the names and abbreviations for the market segments. You must use the
appropriate abbreviation when you fill out your plan lists and data files. Make sure to use the exact
spelling of the abbreviation or you will be unable to upload your data.
Market Segment
Individual market (excluding the student market)
Student market
Fully-insured small group market
Fully-insured large group market (excluding the FEHB line of business)
Self-funded group health plans offered by small employers
Self-funded group health plans offered by large employers
FEHB line of business
•
•

•
•

Abbreviation
(not case sensitive)
Individual market
Student market
Small group market
Large group market
SF small employer plans
SF large employer plans
FEHB plans

P1: Enter individual market or student market. Do not enter more than one market segment in a
cell.
P2: Enter small group market, large group market, SF small employer plans, or SF large employer
plans. If a plan is partially insured and partially self-funded, enter both market segments in the
same cell, separated by a semi-colon. Example: Large group market; SF large employer plans. P2
is the only place where you can put more than one market segment in a single cell.
P3: There isn’t a column for market segment because all plans in P3 are FEHB plans.
D1 – D8: Enter individual market, student market, small group market, large group market, SF
small employer plans, SF large employer plans, or FEHB plans. Do not enter more than one
market segment in a cell.

See Section 5.1 for more information on market segments.

Issuer Name
Location: P2, P3 | Max Length 2048 characters
Enter the issuer name. Do not use slashes.

11

If there is more than one issuer, enter both in the same cell separated by a semicolon. If the plan is not
insured, leave the cell blank.

Issuer EIN
Location: P2, P3 | Format: 9 digits
Enter the issuer 9-digit EIN. Do not enter the 5-digit HIOS Issuer ID. If a plan uses more than one issuer,
enter both in the same cell separated by a semicolon. If the plan is not insured, leave the cell blank.

TPA Name
Location: P2, P3 | Max Length 2048 characters
Enter the TPA name. Do not use slashes. If there is more than one TPA, separate them with a semicolon.
If a plan doesn’t have a TPA, leave the cell blank.

TPA EIN
Location: P2, P3 | Format: 9 digits
Enter the TPA 9-digit EIN. Do not enter the 5-digit HIOS Issuer ID. If there is more than one TPA, separate
them with a semicolon. If a plan doesn’t have a TPA, leave the cell blank.

PBM Name
Location: P1, P2, P3 | Max Length 2048 characters
Enter the PBM name. Do not use slashes. If there is more than one PBM, separate them with a
semicolon. If a plan doesn’t have a PBM, leave the cell blank.

PBM EIN
Location: P1, P2, P3 | Format: 9 digits
Enter the PBM 9-digit EIN. If there is more than one PBM, separate them with a semicolon. If a plan
doesn’t have a PBM, leave the cell blank.

Included in D1 – D8
Location: P1, P2, P3 | Valid Values: 0 or 1 | Must not be blank
Enter 1 if a plan’s data is included in the respective data file in your submission. Enter a 0 if the plan’s
data is not included in the respective data file in your submission. For example, if an issuer is submitting
D1 and D2 on behalf of a plan, the issuer should enter 1 in “Included in D1” and “Included in D2” and
enter 0 for “Included in D3” through “Included in D8.” CMS will use this information to reconcile
submissions when more than one reporting entity is submitting on behalf of a plan.

4.2 HIOS Definitions
HIOS Plan ID in P1
Location: P1 | Max length: 25 characters | Must not be blank in P1
Enter the 14-character Plan ID from HIOS. Do not enter multiple HIOS Plan IDs in the same cell in P1. Do
not leave this cell blank.
Some grandfathered, grandmothered, and student health plans may not have HIOS Plan IDs. If a plan
does not have a HIOS Plan ID, create a unique 14-character plan ID as follows:

12

Grandfathered Plans
(excluding student plans)

Characters
1-5
5-digit HIOS
Issuer ID

Grandmothered Plans
(excluding student plans)

5-digit HIOS
Issuer ID

GM

Generate a unique
7-digit number.

52986GM0000148

Student Health Plans

5-digit HIOS
Issuer ID

SH

Generate a unique
7-digit number.

52986SH0000149

Plan Type

Characters
6-7
GF

Characters
8-14
Generate a unique
7-digit number.

Example
52986GF0000147

HIOS Plan ID in P2
Location: P2 | Max length: 2048 characters | May be blank in P2
The HIOS Plan ID field in P2 is applicable only to fully-insured small group health plans that already have
HIOS Plan IDs. You can enter more than one HIOS Plan ID in a single cell in P2, if applicable. Separate
multiple values with a semicolon. You do not need to create HIOS Plan IDs for group health plans that do
not already have HIOS Plan IDs. If your group health plan isn’t associated with a HIOS Plan ID, leave this
cell blank.

HIOS Plan Name
Location: P1 | Max length 20 characters | Must not be blank
Enter the HIOS Plan Name. If a plan isn’t registered in HIOS, enter the plan marketing name.

4.3 Group Definitions
Group Health Plan Name
Location: P2 | Max length 512 characters | Must not be blank
Enter the group health plan name. Do not use slashes.

Group Health Plan Number
Location: P2 | Max length 25 characters | Must not be blank
Enter a unique plan number. You may use numbers, letters, or punctuation marks (except for slashes).
You may use the Form 5500 plan number as the Group Health Plan Number. If you do, you must also
enter the Form 5500 Plan Number in the Form 5500 Plan Number column. That is, the Form 5500 Plan
Number would be in the Group Health Plan Number column and the Form 5500 Plan Number column.

Form 5500 Plan Number
Location: P2 | Max length 25 characters
If applicable, enter the 3-digit plan number reported on the IRS Form 5500 filed with DOL. If there is
more than one value, separate them with a semicolon.

Plan Sponsor Name
Location: P2 | Max length 2048 characters | Must not be blank
The term plan sponsor means:
• The employer, for an employee benefit plan that a single employer established or maintains;
• The employee organization in the case of a plan of an employee organization; or
13

•

The association, committee, joint board of trustees, or other similar group of representatives of
the parties who establish or maintain the plan, if the plan is established or maintained jointly by
one or more employers and one or more employee organizations, or by two or more employers.

Do not enter more than one plan sponsor name in the same cell unless plan sponsorship changed during
the reference year. In that case, separate the names with a semicolon.
Note: Sometimes the Plan Sponsor Name is the same as the Group Health Plan Name.
Multiple-Employer Plans
If an association or other entity is not the plan sponsor, enter the name of a participating employer as
the sponsor. A plan of a controlled group of corporations should enter the name of one of the
sponsoring members. In either case, use the same name in all future RxDC reports unless there is a
change in sponsorship.
In HIOS, you may upload a supplemental document listing the names and EINs of the participating
employers and/or sponsoring members of the multi-employer plan. This is optional.

Plan Sponsor EIN
Location: P2 | Max length 25 characters | Must not be blank
Enter the 9-digit employer EIN assigned to the plan sponsor. (Ex: 012345679). A multiple-employer plan
or plan of a controlled group of corporations should use the EIN of the entity identified in the Plan
Sponsor Name field.

4.4 FEHB Definitions
FEHB Plan Name
Location: P3 | Max Length 2048 characters | Must not be blank

FEHB Contract Number
Location: P3 | Max Length 2048 characters | Must not be blank
Enter the FEHB Contract ID.

FEHB Plan Code
Location: P3 | Max Length 2048 characters | Must not be blank
Enter the two-digit FEHB plan code as it appears in the FEHB plan brochure. Separate each two-digit plan
code with a semicolon. Ex: 4A; 4B; 4E; 4L.

FEHB Carrier Name
Location: P3 | Max Length 2048 characters | Must not be blank

FEHB Carrier EIN
Location: P3 | Max Length 2048 characters | Must not be blank
9-digit EIN. Include leading zeros if your EIN is fewer than 9 digits. Do not use dashes. Ex: 001234567.

14

FEHB Affiliate Name
Location: P3 | Max Length 2048 characters
(If different from the FEHB carrier.) If there is more than one value, separate them with a semicolon.

FEHB Affiliate EIN
Location: P3 | Max Length 2048 characters
(If different from the FEHB carrier.)
Enter the 9-digit EIN. Include leading zeros if your EIN is fewer than 9 digits. Do not use dashes. Ex:
001234567. If there is more than one value, separate them with a semicolon.

5 Data Aggregation
5.1 Market Segment Aggregation
Reporting entities will aggregate data according to market segment. As noted previously, there are 7
market segments: individual market (excluding the student market), the student market, the fullyinsured small group market, the fully-insured large group market (excluding the FEHB line of business),
self-funded plans offered by small employers, self-funded plans offered by large employers, and the
FEHB line of business.
The market segments are mutually exclusive. Do not report the same data in more than one market
segment.
For mixed-funded plans, which generally self-fund some benefits and fully insure other benefits, report
the self-funded business in the self-funded market segment and the fully-insured business in the fullyinsured market segment. For example, if a large employer self-funds the pharmacy benefit of a plan and
purchases insurance for the medical benefits, the pharmacy benefits would be attributed to the market
segment for self-funded large employer plans and the medical component of the same plan would be
attributed to the fully-insured large group market.
For “minimum premium” plans and similar hybrid arrangements that mimic key aspects of fully-insured
arrangements, or that comply with state insurance laws regarding mandated benefits, report the
business as fully-insured. 6
For level-funded plans, report the business as self-funded.
What if a plan sponsor moves from a fully-insured product to self-funded coverage in the middle of the
reference year (or vice versa)?
Report the fully-insured business in the small group or large group market segments and the self-funded
business in the self-funded small employer or large employer market segments.

“Minimum premium” plans generally have regular fixed premium or funding payments, often based on past
experience, and limit the plan sponsor’s liability for claims.

6

15

Employer Size

For group health plans, the market segment depends on the size of the employer. An employer is
generally considered small if it has 50 or fewer employees and large if it has more than 50 employees.
Fully-insured plans
Use the same market segment that you use for Medical Loss Ratio (MLR) reporting.
Self-funded plans
Determine the number of employees by averaging the total number of all employees employed on
business days during the calendar year preceding the reference year. Use any reasonable method that
takes into account full-time, part-time, and seasonal employees. Examples of reasonable methods
include (1) the full-time equivalent method described in 26 CFR 54.4980H-2(c); (2) if a TPA is affiliated
with an issuer, the counting method used by the issuer for MLR reporting; and (3) if an applicable state
method takes into account non-fulltime employees, the applicable state method.
If the reporting entity for a self-funded plan doesn’t have the necessary information to count the
number of employees, the entity may use a reasonable estimate of employer size. A reasonable method
to estimate employer size for a self-funded plan is to divide the number of employees in the plan by
0.73. 7 For example, if 40 employees are covered by a plan, then the estimated employer size is 55 (40 ÷
0.73 = 55). If you use an estimate for employer size for a self-funded plan, describe the method you used
in your narrative response. If you use an estimation method other than the one described here, explain
why you believe it is a reasonable method.

5.2 State Aggregation
The state aggregation rules for RxDC are like the requirements in the MLR reporting form instructions. In
general, a reporting entity should report fully-insured business in the state where the policy was issued.
For self-funded plans, the reporting entity should generally report the data in the state where the plan
sponsor has its principal place of business. When a plan covers members in multiple states, or when
coverage is sponsored by a group trust, association, or multiple employer welfare arrangement (MEWA),
the reporting entity should follow the instructions below.
Coverage in Multiple States
For self-funded coverage that is not provided through a group trust, association, or MEWA, report the
data in the state where the plan sponsor has its principal place of business. For fully-insured plans,
report the data in the state where the policy was issued. For individual market business sold through an
association, report the data in the state where the certificate of coverage was issued. For FEHB carriers
that are not associated with an issuer, TPA, or other third-party vendor and that offer coverage in
multiple states, report the data in the state where the policy was issued or where the carrier has its
principal place of business.

The divisor is based on estimated take-up rates from the National Compensation Survey, published by the Bureau
of labor statistics. A take-up rate is the percentage of workers with access to a plan who participate in the plan.
The Departments have used the healthcare take-up rate for employers with fewer than 100 employees. See Table
10 at https://www.bls.gov/ncs/ebs/benefits/2021/employee-benefits-in-the-united-states-march-2021.pdf.
7

16

Employer Business through Group Trust, Association, or MEWA
For health coverage provided to plans through a group trust or MEWA, report the data in the state
where the employer (if the plan is sponsored at the individual employer level) or the association (if the
association qualifies as an “employer” under Employee Retirement Income Security Act of 1974 (ERISA)
section 3(5) for purposes of sponsoring the plan) has its principal place of business or the state where
the association is incorporated, in the case of an association with no principal place of business.

5.3 Issuer and TPA Aggregation
Issuers
Within a state and market segment, issuers and their reporting entities must combine the data for all
coverage offered by the same issuer.
If in-network benefits and out-of-network benefits are provided by separate but affiliated issuers, data
may be reported separately for each type by issuer or combined and reported by the issuer that
provides the in-network coverage.
If two unaffiliated issuers provide coverage as part of a package, the issuers must report the data
separately. For example, if one issuer provides inpatient coverage and an unaffiliated issuer provides
outpatient coverage, the submission for the first issuer should contain only the information about the
inpatient coverage and the submission for the other issuer should contain only information about the
outpatient coverage.

TPAs and self-funded plans
A TPA reporting on behalf of self-funded plans should, within each state and market segment, combine
the data for all self-funded plans on whose behalf it is reporting. A self-funded plan is not required to
have a TPA report on its behalf. However, we encourage TPAs to submit RxDC reports on behalf of selffunded plans because it will result in fewer submissions and the total amount of data uploaded into
HIOS will be much smaller. The combined data is also more useful because a TPA or PBM can determine
the Top Drugs based on a larger sample size.

FEHB carriers
A carrier affiliate or associate such as an issuer, TPA, or other third party such as a vendor or
underwriter may be the reporting entity for a FEHB carrier. If a carrier is associated with an issuer, we
generally expect that the issuer will report the FEHB line of business in the FEHB market segment of the
issuer’s submission, rather than the carrier creating a separate submission. Similarly, if a carrier has a
contract with a TPA or other third-party vendor, the Departments and OPM expect the TPA or other
third-party vendor to report the FEHB line of business data in the FEHB market segment of the TPA’s or
other third-party vendor’s submission.
If a carrier chooses to make its own submission, it needs to make sure that the issuer, TPA, or vendor
does not report the same data. If a carrier is associated with more than one issuer, TPA, or vendor, the
carrier should aggregate data for plans that share the same issuer, TPA, or vendor. If a carrier offers
plans that are not associated with an issuer, TPA, or vendor, the carrier should combine the data for
those plans.

17

PBMs
If a PBM is the reporting entity, the rules for aggregating data by issuer and TPA also apply. For example,
if a PBM is reporting data for three issuers, the PBM should aggregate the data separately for each
issuer. If a PBM is reporting for 10 self-funded plans that have two different TPAs, the PBM should
combine the data for the self-funded plans that share each TPA separately.

Aggregation Restriction
Pursuant to 26 CFR 54.9825-5T(b)(2)(i), 29 CFR 2590.725-3(b)(2)(i), and 45 CFR 149.730(b)(2)(i), the data
submitted in files D1 and D3 – D8 must not be aggregated at a less granular level than the aggregation
level used by the reporting entity that submitted the data in file D2 Spending by Category. This means
that:
•
•

If the data submitted in D2 IS NOT aggregated by the issuer or TPA (that is, the reporting entity
for D2 reports the data separately for each group health plan), the data in D1, D3, D4, D5, D6,
D7, and D8 must also be reported separately for each plan.
If the data submitted in D2 IS aggregated (that is, not reported at the plan level), then the
reporting entities for the other data files can choose whether they want to report information at
the plan level or at the aggregate level. The reporting entities for the other data files don’t have
to make the same decision for each of the other files. For example, if D2 is at the aggregate
level, a reporting entity could choose to submit D1 at the plan level and D4 at the aggregate
level.

5.4 Examples of Aggregate Reporting
Below are examples of aggregated data files.
Note on Terminology: In HIOS, a 5-digit HIOS Issuer ID is assigned to an issuer in a specific state in which
it operates. Therefore, if an insurance company that has a unique 9-digit EIN operates in multiple states,
it will have multiple HIOS Issuer IDs. In these instructions, for simplicity, the term “issuer” refers to the
insurance company at the EIN level when that is appropriate in context, such as in the examples below.
Example 1: Issuer reports for fully-insured plans
Issuer A reports total spending in California in the individual, small group, and large group markets, and
in Washington for the individual and student markets.
Issuer or TPA EIN State
Market Segment
Total Spending
Total Cost Sharing
EIN for Issuer A
EIN for Issuer A
EIN for Issuer A
EIN for Issuer A
EIN for Issuer A

CA
CA
CA
WA
WA

Individual market
Small group market
Large group market
Individual market
Student market

$177,141,997
$8,419,411
$23,735,387
$168,409
$377,582

$21,733,552
$1,099,238
$3,061,628
$22,107
$55,690

Example 2: Issuer reports for multiple issuers in the same holding group
Issuer X, Issuer Y, and Issuer Z are part of the same holding group. Issuer X reports on behalf of itself and
also on behalf of Issuer Y and Issuer Z.
Issuer or TPA EIN State
Market Segment
Total Spending
Total Cost Sharing

18

EIN for Issuer X
EIN for Issuer X
EIN for Issuer X
EIN for Issuer X
EIN for Issuer X
EIN for Issuer Y
EIN for Issuer Y
EIN for Issuer Y
EIN for Issuer Y
EIN for Issuer Z

CO
CO
CO
ID
WY
PA
PA
NY
NJ
NJ

Individual market
Small group market
Large group market
Large group market
Large group market
Small group market
Large group market
Small group market
Small group market
Small group market

$10,437
$333,803,307
$107,047,027
$219,568
$73,114
$7,234,076
$231,331,535
$7,234,076
$23,375,484
$1,781,722

$1,404
$39,962,932
$15,617,091
$26,072
$9,362
$1,002,860
$27,706,578
$1,009,009
$2,696,362
$240,568

Example 3: Issuer reports for fully-insured plans, FEHB plans, and self-funded plans
Issuer B both sells insurance and provides administrative services for self-funded plans. Issuer B reports
total spending in Colorado in the individual, small group, and large group markets and for self-funded
large employer plans; in Idaho in the individual, small group, and large group markets; and in Wyoming
for self-funded large employer plans. Issuer B is also associated with an FEHB carrier and reports for
FEHB plans in Colorado.
Issuer or TPA EIN State
Market Segment
Total Spending
Total Cost Sharing
EIN for Issuer B
EIN for Issuer B
EIN for Issuer B
EIN for Issuer B
EIN for Issuer B
EIN for Issuer B
EIN for Issuer B
EIN for Issuer B

CO
CO
CO
CO
ID
ID
ID
WY

Individual market
Small group market
FEHB plans
SF large employer plans
Individual market
Small group market
Large group markets
SF large employer plans

$58,971,803
$338,403
$728,966,601
$219,568
$150,268
$25,441,865
$1,295,869
$170,953,419

$9,304,571
$35,147
$88,562,152
$30,149
$23,162
$3,912,450
$168,839
$26,331,955

Example 4: TPA reports for self-funded plans
TPA C reports total spending for self-funded small employers and self-funded large employers in
multiple states.
Issuer or TPA EIN
State
Market Segment
Total Spending
Total Cost Sharing
EIN for TPA C
EIN for TPA C
EIN for TPA C
EIN for TPA C
EIN for TPA C
EIN for TPA C

KY
KY
LA
MI
MI
MN

SF small employer plans
SF large employer plans
SF small employer plans
SF small employer plans
SF large employer plans
SF large employer plans

$162,827,074
$404,143,910
$370,421
$455,249,960
$1,077,284,699
$2,386,062

$17,407,842
$51,431,354
$49,929
$70,231,411
$142,352,400
$307,850

Example 5: PBM reports data on behalf of fully-insured plans and self-funded plans
A PBM reports prescription drug rebates for fully-insured plans offered by Issuer D and Issuer E and for
self-funded plans administered by TPA F, TPA G, and Issuer D. (See Section 9.2 for information about
allocating prescription drug rebates across plans, issuers, carriers, states, and markets.)

19

EIN
EIN for Issuer D
EIN for Issuer D
EIN for Issuer D
EIN for Issuer D’s
TPA Business
EIN for Issuer D
EIN for Issuer E
EIN for Issuer E
EIN for TPA F
EIN for TPA F
EIN for TPA G
EIN for TPA G

State

Market Segment

CO
CO
CO
CO

Individual market
Small group market
Student market
SF small employer plans

Total Rx Spending
under Pharmacy
Benefit
$210
$10,714
$2,962,333
$4,483

WY
PA
PA
NY
NJ
CT
CT

Large group market
Small group market
Large group market
SF small employer plans
SF small employer plans
SF small employer plans
SF large employer plans

$1,296
$205,705
$5,142,346
$186,672
$1,460,734
$4,095,437
$776,632

Total Rebates, Fees
and Other
Remuneration
$65
$2,278
$669,043
$1,372
$456
$45,212
$1,445,822
$45,212
$483,284
$897,556
$296,518

Example 6: Plan sponsor self-reports for fully-insured plans and self-funded plans
An employer with 10,000 employees is headquartered in Nevada and has employees in Nevada, Utah,
and Arizona. In each state, employees can choose among several options. Some of the options are fullyinsured through Issuer H and some of the plans are self-funded and administered by TPA I. To help
facilitate data analysis and identify duplicate submissions, the first column should be the EIN of the
issuer or TPA of the plans, rather than the EIN of the plan sponsor. (If a self-funded plan is selfadministered and doesn’t use a TPA, then you can use the EIN of the plan sponsor.)
EIN
EIN for Issuer H
EIN for TPA I

State
NV
NV

Market Segment

Total Spending

Large group market
SF large employer plans

$ 9,619,527
$34,540,901

Total Cost Sharing
$1,119,521
$5,485,786

6 Premium and Life-Years
Use the definitions in this section to report premium and life-years in D1 Premium and Life-Years.

Life-years
Location: D1 | Max decimals: 8
Life-years are the average number of members throughout the year. As noted above, the term member
means a person who has health coverage, regardless of whether the coverage is associated with an
insurance policy, a group health plan, or an FEHB plan. For example, enrollees, dependents, participants,
beneficiaries, and FEHB annuitants are all considered members.
To calculate life-years, you must first calculate member months.
To calculate member months:
1. Count the number of members covered on a given day of each month of the reference year
2. Add the number of members from Step 1 to calculate total member months for the reference
year

20

To calculate life-years:
1. Divide member months by 12
2. Round the resulting number to the 8th decimal place
Example: Calculating member months and life-years
Members covered
Date
by the plan on the given date
January 1, 2020
882
February 1, 2020
872
March 1, 2020
884
April 1, 2020
921
May 1, 2020
924
June 1, 2020
923
July 1, 2020
925
August 1, 2020
916
September 1, 2020
907
October 1, 2020
906
November 1, 2020
902
December 1, 2020
869
Total Member Months
10,831
# of Life-Years
902.58333333
(Total member months / 12)

Earned premium (fully-insured coverage)
Location: D1 | Max decimals: 8
Earned premium means all money paid by a member, policyholder, subscriber, and/or plan sponsor as a
condition of the member receiving coverage. Earned premium includes any fees or other contributions
associated with the health plan. For FEHB plans, earned premium means the member and government
shares of premium. Report earned premium on a direct basis, without factoring in reinsurance. Include
advance payments of the premium tax credit (APTCs), if applicable. Do not reduce the amount of earned
premium to reflect state or federal MLR rebates.

Premium equivalents (self-funded coverage)
Location: D1 | Max decimals: 8
For self-funded plans and other arrangements that do not rely exclusively or primarily on premiums,
report the premium equivalent amounts representing the total cost of providing and maintaining
coverage, including claims costs, administrative costs, Administrative Services Only (ASO) and other TPA
fees, and stop-loss premiums. An employer with a self-funded plan may use, as the total cost of
providing and maintaining coverage, the same costs that are taken into account for purposes of
calculating COBRA premiums (minus the 2% administration charge, if applicable).

ASO and other TPA fees paid
Location: D1 | Max decimals: 8
Report the ASO and other fees paid to the TPA. This amount should also be included in Premium
Equivalents.

21

Stop loss premium paid
Location: D1 | Max decimals: 8
Report the stop loss premium paid to the insurer. This amount should also be included in Premium
Equivalents.

Average monthly premium paid by members
Location: D1 | Max decimals: 8
Report the average monthly premium per member per month (PMPM) paid by members.
Include:
• Premium paid by members
• APTCs
Premium equivalents paid by members for self-funded coverage
Exclude:
•
•

Premium paid by employers or other plan sponsors on behalf of members.
Premium equivalents paid by employers or other plan sponsors on behalf of members

Formula:

𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴 𝑚𝑚𝑜𝑜𝑜𝑜𝑜𝑜ℎ𝑙𝑙𝑙𝑙 𝑝𝑝𝑝𝑝𝑝𝑝𝑝𝑝𝑝𝑝𝑝𝑝𝑝𝑝 𝑝𝑝𝑝𝑝𝑝𝑝𝑝𝑝 𝑏𝑏𝑏𝑏 𝑚𝑚𝑚𝑚𝑚𝑚𝑚𝑚𝑚𝑚𝑚𝑚𝑚𝑚 =

𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇 𝑝𝑝𝑝𝑝𝑝𝑝𝑝𝑝𝑝𝑝𝑝𝑝𝑝𝑝 𝑝𝑝𝑝𝑝𝑝𝑝𝑝𝑝 𝑏𝑏𝑏𝑏 𝑚𝑚𝑚𝑚𝑚𝑚𝑚𝑚𝑚𝑚𝑚𝑚𝑚𝑚
𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇 𝑚𝑚𝑚𝑚𝑚𝑚𝑚𝑚𝑚𝑚𝑚𝑚 𝑚𝑚𝑚𝑚𝑚𝑚𝑚𝑚ℎ𝑠𝑠

To calculate average monthly premium paid by members at the aggregate level (EIN, state, market
segment), you have two options:
•
•

Calculate the amount for each plan and then take the weighted average across plans in the
aggregation level, using member months as the weight; or
Calculate the amount using total level data from all the plans in the aggregation level.

Average monthly premium paid by employers
Location: D1 | Max decimals: 8
Not applicable in the individual or student markets. For group health plans and FEHB plans, report the
average monthly premium PMPM paid by employers on behalf of members.
Include:
• Premium paid by employers and other plan sponsors on behalf of members (including
dependents). 8
• Premium equivalents for self-funded coverage.
• Premium paid by group trust, association, or MEWA plans if separate employers or other plan
sponsors make premium contributions.

For FEHB plans, the amount paid by the employer is the government contribution within the meaning of Title 5
USC Chapter 89.

8

22

Exclude:
•

Premium paid by members

Formula:
𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴 𝑚𝑚𝑚𝑚𝑚𝑚𝑚𝑚ℎ𝑙𝑙𝑙𝑙 𝑝𝑝𝑝𝑝𝑝𝑝𝑝𝑝𝑝𝑝𝑝𝑝𝑝𝑝 𝑝𝑝𝑝𝑝𝑝𝑝𝑝𝑝 𝑏𝑏𝑏𝑏 𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒 =

𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇 𝑝𝑝𝑝𝑝𝑝𝑝𝑝𝑝𝑝𝑝𝑝𝑝𝑝𝑝 𝑝𝑝𝑝𝑝𝑝𝑝𝑝𝑝 𝑏𝑏𝑏𝑏 𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒
𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇 𝑚𝑚𝑚𝑚𝑚𝑚𝑚𝑚𝑚𝑚𝑚𝑚 𝑚𝑚𝑚𝑚𝑚𝑚𝑚𝑚ℎ𝑠𝑠

To calculate the value at the aggregate level (EIN, state, market segment), you have two options:
•
•

Calculate the amount for each plan and then take the weighted average across all plans in the
aggregation level, using member months as the weight; or
Calculate the amount using total level data from all the plans in the aggregation level.

How do I compute the weighted average?
To calculate the weighted average monthly premium paid by members:
1. Calculate the average monthly premium paid by members for each plan in the aggregation level
(formula box above)
2. For each plan, multiply the amount in Step 1 by the number of member months in the plan
3. Calculate the sum of the amount in Step 2 for all plans in the aggregation level
4. Calculate the sum the number of member months for all plans in the aggregation level
5. Divide the amount in Step 3 by the amount in Step 4
Use the same method to calculate the weighted average monthly premium paid by employers.
What if I don’t know the amount of premium paid by members versus employers?
Average monthly premium paid by enrollees and average monthly premium paid by employers are data
elements required by Section 204 of the CAA and the Prescription Drug and Health Care Spending
interim final rules (86 FR 66662). Generally, if you are reporting on behalf of a group health plan or FEHB
plan, you must obtain this information from the plan.
For the 2020 and 2021 reference years only
If you have obtained the required information, you must report it. However, the Departments recognize
there may be significant challenges to obtain information about employer premium contributions,
especially when a contractual relationship began before the passage of the CAA. Accordingly, the
Departments will not take enforcement action related to the requirement to report average monthly
premium paid by employers versus members for the 2020 and 2021 reference years if those data
elements are reported in RxDC report for the 2022 reference year and all future reference years.

7 Spending
Report data related specifically to the reference year and paid or received through March 31 of the
calendar year immediately following the reference year. For accounting purposes, this is sometimes
referred to as “incurred in 12, paid or received in 15.” (For non-calendar plan years, include only the
portion of experience that was incurred during the reference year and paid or received through March

23

31 of the following calendar year.) For the 2020 and 2021 reference years, you may choose to use a
valuation date that is later than March 31.

7.1 Definitions
Total spending
Location: D2, D3, D4, D5, D7, D8 | Max decimals: 8
Report allowed claims with dates of service during the reference year. Allowed claims are the total
payments made under the plan or policy to health care providers on behalf of members. Report claims
on a direct basis (that is, before reinsurance, unless specifically stated otherwise in these instructions).
Include in Total Spending
• Payments by
the plan, issuer,
or carrier
• Cost sharing
paid by
members
• Claims liability,
including claims
incurred during
the reference
year but not
paid or not
reported as of
March 31 of the
year following
the reference
year (such as
claims reported
but still in the
process of
adjustment or
payment)

•

•

•

Subtract
Net payments from any
federal or state
reinsurance or costsharing reduction
arrangement or
program
Prescription drug
rebates, fees, and
other remuneration (In
other words, total
spending is net of
prescription drug
rebates, fees, and
other remuneration.)
Manufacturer costsharing assistance, to
the extent known

•

•

•

•

Exclude
Ineligible claims, such as
duplicate claims, recovered
claims overpayments, thirdparty liabilities (e.g.,
coordination of benefits
claims), and any other
claims that are denied under
the policy’s or plan’s terms
Payments for services other
than medical care (e.g.,
medical management,
quality improvement, and
fraud detection and
recovery expenses)
Active life reserves (policy
reserves, contract reserves,
contingency reserves, or any
kind of reserves except
traditionally defined
reserves for claims incurred
but not reported) or change
in such reserves
Charges or payments from
state or federal risk
adjustment programs

Total cost sharing
Location: D2, D3, D4, D5, D7, D8| Max decimals: 8
Include cost sharing when you report Total Spending, and also as a separate data element.
Include in Total Cost
Sharing
• Deductibles,
coinsurance, and
copays, including
amounts that may have

Subtract
•

Cost sharing paid by a member’s
secondary insurance, to the
extent known

Exclude
•

Cost sharing reductions the
issuer paid on behalf of the
member under federal or
state cost-sharing reduction
24

Include in Total Cost
Sharing
been paid through a
health savings or
reimbursement
account

Subtract
•

Exclude

Prescription drug rebates, fees,
and other remuneration that are
passed to members at the pointof-sale, if not already accounted
for as reduced cost sharing
amounts paid by members.

•
•

programs (include these
amounts in total spending
but not in total cost sharing)
Premium
Manufacturer cost-sharing
assistance

Manufacturer cost-sharing assistance
Location: D3, D4, D5, D7, D8| Max decimals: 8
Report manufacturer cost-sharing assistance amounts paid on behalf of members, such as coupons or
copay cards, to the extent information is available.

Amounts not applied to deductible or out-of-pocket maximum
Location: D2 | Max decimals: 8
Report billed amounts that were (1) not applied to a member’s deductible or out-of-pocket maximum,
(2) not paid by the plan, issuer, or carrier, and (3) not included in Total Spending.
Include:
•
•

Disallowed amounts for non-covered services or for prescription drugs not on a plan or coverage’s
formulary
Cost-sharing amounts not applied to the deductible or out-of-pocket maximum. For example, if
manufacturer cost-sharing assistance is not counted towards a member’s deductible or out-ofpocket maximum as part of an accumulator adjustment program. 9

7.2 Spending Categories
Location: D2| Max length: 256 characters | Must not be blank
The following table has the spending category names and abbreviations. You must use the abbreviation
when you fill out data file D2. Make sure to use the exact spelling of the abbreviation or you will be
unable to upload your data.
Spending Category

Abbreviation (Not case sensitive)

Hospital
Primary care
Specialty care
Other medical costs and services
Medical benefit drugs: known amounts
(informational)

Hospital
Primary care
Specialty care
Other medical costs and services
Known medical benefit drugs

Medical benefit drugs: estimated amounts
(informational)

Estimated medical benefit drugs

A copay accumulator program, sometimes referred to as accumulator adjustment or maximizer program, is a
policy under which the value of manufacturer cost-sharing assistance amounts, such as coupons or copay cards,
are not applied to a member’s deductible and/or out-of-pocket maximum

9

25

Mutual Exclusiveness and Double-Reporting
The hospital, primary care, specialty care, and other medical costs and services spending categories are
mutually exclusive of each other and include known and estimated spending on medical benefit drugs
billed under those categories. Spending on medical benefit drugs must also be reported in the
respective categories for medical benefit drugs. This means that medical benefit drug spending is
“double-reported.”
Capitation
Total spending includes spending for partial and full capitated services. You must estimate the portion of
spending for capitated services that is attributable to each spending category and allocate it accordingly.
Pharmacy Benefit Drugs
Do NOT report spending on pharmacy benefit drugs anywhere in D2 Spending by Category. (This is a
change from the instructions published on November 23, 2021.)

Hospital
Location: D2| Max decimals: 8
Report spending on services provided by hospitals to members and billed by the facility.
Include in Hospital
All inpatient and outpatient facility services billed by the facility, including:
• Any claim meeting one or more of the following criteria:
A. Place of Service codes 21, 31, 32, 33, 34, 51, 56, or 61
B. Medicare Severity Diagnosis-Related Group (MS-DRG) code
C. All claims with revenue codes 010X – 021X, or a valid revenue code
on the UB-04 form and a CPT/HCPCS code. Below are examples of
hospital spending:
o Revenue codes 036X, 048X, 049X, 079X and CPT/HCPCS codes
10004-69999
o Revenue codes 045X and CPT/HCPCS codes 99281-99292
• Room and board, ancillary charges, services of resident providers,
inpatient pharmacy, hospital-based nursing home and hospice care, and
any other services billed by hospitals
• Services provided in psychiatric and substance abuse hospitals
• Facility services for medical, surgical, lab, radiology, therapy, maternity,
skilled nursing, and other services that are billed by the facility
• Include outpatient care, emergency services, or ambulance services only
if billed by the facility
• Medications dispensed by an institutional pharmacy and administered
on-site as part of a medical service. These include but not are not limited
to CPT/HCPCS codes J0000–J9999.

•

•

•

•

Exclude
Any medication
covered under the
pharmacy benefit
Amounts reported
in primary care,
specialty care, or
other medical
costs and services
Provider services
if independently
billed
Laboratory and
radiology services
that are billed
independently by
the laboratory
(report these
amounts in other
medical costs and
services)

Primary care
Location: D2| Max decimals: 8
Report spending on clinical health care services provided by a primary care provider in a doctor’s office
or outpatient care center. For the purposes of the RxDC report, a primary care provider is, generally, a
26

provider who (1) has a primary specialty designation of family medicine, internal medicine, geriatric
medicine, or pediatric medicine and (2) is accountable for addressing a large majority of personal health
care needs, developing a sustained partnership with patients, and practicing in the context of family and
community.
Include in Primary Care
• Services billed with the following CPT/HCPCS codes and
taxonomy codes:
o 99381-99397, 99460-99464
o 99202-99215, 99304-99350, G0402, G0438, G0439 and one
of the taxonomy codes in the table below
• Clinical health care services provided by other clinicians, such as
nurse practitioners, clinical nurse specialists, or physician
assistants, in a primary care setting
• Obstetrics and gynecology clinical health care services if
performed by a primary care provider
• Administration of medications dispensed by an institutional
pharmacy and administered on-site as part of a clinical health
care service.
Primary Care Taxonomy Codes
Taxonomy
Taxonomy
Code
Provider Type

Exclude
• Amounts reported in
hospital, specialty care, or
other medical costs and
services
• Laboratory and radiology
services provided in a
primary care setting that are
billed independently by the
laboratory (report these
amounts in other medical
costs and services)

Taxonomy
Classification

Taxonomy Specialty

163WC1500X

NURSING SERVICE PROVIDERS

REGISTERED NURSE

COMMUNITY HEALTH

163WG0000X

NURSING SERVICE PROVIDERS

REGISTERED NURSE

GENERAL PRACTICE

207QA0505X

ALLOPATHIC & OSTEOPATHIC
PHYSICIANS
ALLOPATHIC & OSTEOPATHIC
PHYSICIANS
ALLOPATHIC & OSTEOPATHIC
PHYSICIANS
ALLOPATHIC & OSTEOPATHIC
PHYSICIANS
ALLOPATHIC & OSTEOPATHIC
PHYSICIANS
ALLOPATHIC & OSTEOPATHIC
PHYSICIANS
ALLOPATHIC & OSTEOPATHIC
PHYSICIANS
ALLOPATHIC & OSTEOPATHIC
PHYSICIANS
ALLOPATHIC & OSTEOPATHIC
PHYSICIANS
ALLOPATHIC & OSTEOPATHIC
PHYSICIANS

FAMILY PRACTICE

ADULT MEDICINE

INTERNAL MEDICINE

GERIATRIC MEDICINE

FAMILY PRACTICE

ADOLESCENT MEDICINE

FAMILY MEDICINE

GERIATRIC MEDICINE

INTERNAL MEDICINE

NOT APPLICABLE

INTERNAL MEDICINE

ADOLESCENT MEDICINE

PEDIATRICS

NOT APPLICABLE

PEDIATRICS

ADOLESCENT MEDICINE

GENERAL PRACTICE

NOT APPLICABLE

PREVENTIVE
MEDICINE

261QC1500X

AMBULATORY HEALTH CARE FACILITIES

CLINIC/CENTER

PUBLIC HEALTH &
GENERAL PREVENTIVE
MEDICINE
COMMUNITY HEALTH

261QR1300X

AMBULATORY HEALTH CARE FACILITIES

CLINIC/CENTER

RURAL HEALTH

207RG0300X
207QA0000X
207QG0300X
207R00000X
207RA0000X
208000000X
2080A0000X
208D00000X
2083P0901X

27

261QP2300X

AMBULATORY HEALTH CARE FACILITIES

CLINIC/CENTER

PRIMARY CARE

363A00000X

PHYSICIAN ASSISTANTS AND ADVANCED
PRACTICE NURSING
PHYSICIAN ASSISTANTS AND ADVANCED
PRACTICE NURSING
PHYSICIAN ASSISTANTS AND ADVANCED
PRACTICE NURSING
PHYSICIAN ASSISTANTS AND ADVANCED
PRACTICE NURSING
PHYSICIAN ASSISTANTS AND ADVANCED
PRACTICE NURSING
PHYSICIAN ASSISTANTS AND ADVANCED
PRACTICE NURSING
PHYSICIAN ASSISTANTS AND ADVANCED
PRACTICE NURSING
PHYSICIAN ASSISTANTS AND ADVANCED
PRACTICE NURSING
AMBULATORY HEALTH CARE FACILITIES

PHYSICIAN ASSISTANT

NOT APPLICABLE

PHYSICIAN ASSISTANT

MEDICAL

NURSE PRACTITIONER

NOT APPLICABLE

NURSE PRACTITIONER

ADULT HEALTH

COMMUNITY HEALTH

NOT APPLICABLE

NURSE PRACTITIONER

FAMILY

NURSE PRACTITIONER

GERONTOLOGY

NURSE PRACTITIONER

PEDIATRICS

CLINIC/CENTER

STUDENT HEALTH

PRIMARY CARE

NOT APPLICABLE

NURSE PRACTITIONER

WOMEN'S HEALTH

FAMILY MEDICINE

NOT APPLICABLE

364SA2200X

PHYSICIAN ASSISTANTS AND ADVANCED
PRACTICE NURSING
PHYSICIAN ASSISTANTS AND ADVANCED
PRACTICE NURSING
ALLOPATHIC & OSTEOPATHIC
PHYSICIANS
NURSING SERVICE PROVIDERS

ADULT HEALTH

364SC1501X

NURSING SERVICE PROVIDERS

364SF0001X

NURSING SERVICE PROVIDERS

364SP0200X

NURSING SERVICE PROVIDERS

CLINICAL NURSE
SPECIALIST
CLINICAL NURSE
SPECIALIST
CLINICAL NURSE
SPECIALIST
CLINICAL NURSE
SPECIALIST

363AM0700X
363L00000X
363LA2200X
363LC1500X
363LF0000X
363LG0600X
363LP0200X
261QS1000X
363LP2300X
363LW0102X
207Q00000X

COMMUNITY HEALTH
FAMILY HEALTH
PEDIATRICS

Specialty care
Location: D2| Max decimals: 8
Report spending on clinical health care services provided by specialists. A specialist is, generally, a
provider that focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent,
or treat certain types of diseases, symptoms, and conditions.
Include in Specialty Care
All professional services not inclusive of primary care, including
the following:
• Providers that have training in a specific area of health care
and are not considered primary care providers as defined
above
• Chiropractors, podiatrists, optometrists, and physical,
occupational, and speech therapists that are not billed as part
of hospital or facility services

•

•
•

Exclude
Amounts reported in
hospital, primary care, or
other medical costs and
services
Dental services (report in
Other medical costs and
services)
Laboratory and radiology
services associated with

28

•
•
•

Include in Specialty Care
Doctor’s office or outpatient care center services provided by
specialists
Hospital-based specialist services only if the specialist
independently bills for those services
Administration of medications dispensed by an institutional
pharmacy and administered on-site as part of a clinical health
care service.

Exclude
specialty care in a doctor’s
office or outpatient care
center that are billed
independently by the
laboratory (report these
amounts in other medical
costs and services)

Other medical costs and services
Location: D2| Max decimals: 8
Report spending for all other professional and facility clinical health care services and equipment not
reported as hospital, primary care, or specialty care.
Include in Other medical costs and services
Report spending for all other professional and facility clinical health care
services and equipment not reported as hospital, primary care, or specialty
care. Examples as follows:
•
•
•
•
•
•
•
•

Radiology and laboratory services that are billed independently by the
laboratory (Radiology: 70000–79999; laboratory and pathology: 36415;
36416; 80000–89999)
Non-hospital based skilled nursing and hospice services
Ambulance services not billed by a hospital facility
Home health care
Dental services and supplies
Vision services and supplies
Durable medical equipment
Wellness services billed on a claim. Do not include wellness services
that are not covered services under a plan or policy. For the purposes
of the RxDC report, wellness services are defined as activities
primarily designed to implement, promote, and improve health.

•

•

•

Exclude
Amounts reported
in hospital, primary
care, or specialty
care
Claims with a valid
revenue code on
the UB-04 form.
Wellness services
not billed on a
claim

Medical benefit drugs: known amounts (informational)
Location: D2| Max decimals: 8 | Abbreviation: Known medical benefit drugs
Report spending on drugs covered under a medical benefit that are separately billed or otherwise
known exactly. The amounts reported here are also included in the hospital, primary care, specialty
care, or other medical costs and services categories.
Complete the column for Total Spending (including cost sharing). You are not required to complete the
Total Cost Sharing or Amounts Not Applied to Deductible and/or Out-of-Pocket Maximum columns for
this informational category.

Medical benefit drugs: estimated amounts (informational)
Location: D2| Max decimals: 8 | Abbreviation: Estimated medical benefit drugs
Report the estimated portion of bundled or alternative payment arrangements (or other non-fee-forservice amounts) that can be attributed to drugs covered under a medical benefit. The amounts

29

reported must also be reported in the hospital, primary care, specialty care, or other medical costs and
services categories. You must estimate spending on prescription drugs included in the bundle or other
alternative payment arrangement in good faith and to the best of your ability. If you report estimated
amounts, explain the circumstances and describe the method you used in the Narrative Response.
Complete the column for Total Spending (including cost sharing). You are not required to complete the
Total Cost Sharing or Amounts Not Applied to Deductible and/or Out-of-Pocket Maximum columns for
this informational category.
Example: Data aggregated by spending category
EIN

State

Market Segment

Spending Category

Total
Spending

Total Cost
Sharing

$1,240,100

$183,990

Amounts Not
Applied to
Deductible
and/or Out-ofPocket Maximum
$10,920

123456789

ND

Individual market

Hospital

123456789

ND

Individual market

Primary Care

$459,300

$10,200

$890

123456789

ND

Individual market

Specialty Care

$873,300

$340,000

$2,680

123456789

ND

Individual market

Other medical
costs and services
Known medical
benefit drugs
Estimated medical
benefit drugs

$428,800

$165,900

$8,550

123456789

ND

Individual market

123456789

ND

Individual market

$211,560
$145,556

8 Prescription Drug Reporting
8.1 Prescription Drug Coverage
Medical benefit drugs
Location: D2
Report information about prescription drugs covered under a medical benefit in D2. You must estimate
the portion of bundled or alternative payment arrangements that can be attributed to medical benefit
drugs in good faith and to the best of your ability.

Pharmacy benefit drugs
Location: D3, D4, D5, D6, D7, D8
Report information about prescription drugs covered under the pharmacy benefit in data files D3, D4,
D5, D6, D7, and D8.

8.2 Drug Aggregation
Prescription drug definition
For the purposes of RxDC reporting, a prescription drug is defined as a set of National Drug Codes 10
(NDCs) that are grouped together by name and ingredient. This means that NDCs with the same
The Food & Drug Administration (FDA) assigns a unique National Drug Code to each pharmaceutical product
manufactured, prepared, propagated, compounded, or processed for sale in the United States.
10

30

ingredient are grouped together even if they have different strengths, dosage forms (ex: capsule, tablet,
liquid), routes of delivery (ex: oral, injection), labeler names (manufacturer, re-packager, or distributor),
or package types or sizes. For example, if the same active ingredient is available as both a tablet or as a
liquid, both forms are considered the same drug for RxDC reporting, unless they have different brand
names.

Drug names and codes
Location: D3, D4, D5, D8 | Must not be blank
Drug Name Max Length: 2048 | Drug Code Max Length: 100
The RxDC drug name for brand prescription drugs is the combination of the ingredient name and the
brand name. 11 The brand name is enclosed in brackets. Specifically, the format of the RxDC drug name
is: ingredient name [brand name]. For generic drugs, the RxDC drug name is just the ingredient name.
For the purposes of RxDC reporting, branded generics and authorized generics are treated the same as
unbranded generics. 12 Thus, the RxDC drug name for branded generics and authorized generics is just
the ingredient name.
If an NDC has more than one ingredient, the RxDC drug name contains all ingredients. The ingredients
are separated from each other using a pipe symbol (“|”) with a space on both sides of the pipe symbol.
For example, the RxDC drug name for a generic drug with two ingredients is: ingredient 1 | ingredient 2.
The RxDC drug name for a brand prescription drug with two ingredients is: ingredient 1 | ingredient 2
[brand name]. The ingredients are listed in alphabetic order.
Each RxDC drug name has a unique RxDC drug code. The RxDC names and codes are in the CMS Drug
and Therapeutic Class Crosswalk at https://www.cms.gov/CCIIO/Programs-and-Initiatives/OtherInsurance-Protections/Prescription-Drug-Data-Collection.
Example: Crosswalk from NDC to RxDC drug name and code (excerpt for mesalamine)
11-Digit
NDC
000939
22489
540920
10001
597620
11701
597620
11803

Labeler

Teva
Pharmaceuticals
Takeda

Brand
Indicator
Generic°
Generic°

Greenstone LLC

Generic°

Greenstone LLC

Generic

Strength, Dosage Form, and
Package
375 mg/1, 120 capsule, extended
release in 1 bottle
1.2 g/1, 120 tablet, delayed release
in 1 bottle
400 mg/1, 180 capsule, delayed
release in 1 bottle
1000 mg/1, 30 suppositories in 1
box

RxDC
Drug Name
mesalamine
mesalamine
mesalamine
mesalamine

RxDC
Drug Code
R005258201
01000
R005258201
01000
R005258201
01000
R005258201
01000

11
For the purposes of RxDC reporting, the Departments generally use the brand name and active ingredient name
from RxNorm. RxNorm is a standardized drug naming convention for clinical drugs produced by the U.S. National
Library of Medicine. See https://www.nlm.nih.gov/research/umls/rxnorm/index.html for more information about
RxNorm.
12
Branded generics are marketed under a brand name but go through the same FDA approval process as
unbranded generics. Branded generics and unbranded generics may only be sold after the brand prescription drug
loses marketing exclusivity. Authorized generics are created by makers of brand prescription drugs under the same
New Drug Approval (NDA) authorization as the original brand prescription drug. Authorized generics may be
marketed before the brand prescription drug loses marketing exclusivity.

31

606870 American Health
Generic
55632
Packaging
625590 ANI
Generic°
42007
Pharmaceuticals
692381 Amneal
Generic
27403
Pharmaceuticals
699180 Amring
Generic
56030
Pharmaceuticals
707711 Cadila Healthcare
Generic
11002
707711 Cadila Healthcare
Generic^
35302
433530 Aphena Pharma
Brand
88479
Solutions
656490 Salix
Brand
10301
Pharmaceuticals
000235 Allergan, Inc.
Brand
90118
589140 Allergan, Inc.
Brand
50101
000235 Allergan, Inc.
Brand
85318
500903 A-S Medication
Brand
00200
Solutions
540920 Takeda
Brand
47601
540920 Takeda
Brand
18981
000370 Meda
Brand
02207
Pharmaceuticals
000370 Meda
Brand
06603
Pharmaceuticals
° Authorized generic; ^ Branded generic

400 mg/1, 20 blister pack in 1 box,
unit-dose
4 g/60mL, 7 bottles in 1 box

mesalamine

1000 mg/1, 30 suppositories in 1
carton
1000 mg/1, 30 suppositories in 1
box
800 mg/1, 10 tablet, delayed
release in 1 blister pack
800 mg/1, 10 tablet, delayed
release in 1 blister pack
375 mg/1, 2160 capsule, extended
release in 1 bottle
375 mg/1, 1 bottle in 1 carton

mesalamine

800 mg/1, 180 tablet, delayed
release in 1 bottle
1000 mg/1, 3 suppository, 1 box
400 mg/1, 180 capsule, delayed
release in 1 bottle
400 mg/1, 180 capsule, delayed
release in 1 bottle
1.2 g/1, 120 tablet, delayed release
in 1 bottle
250 mg/1, 240 capsules in 1 bottle
4 g/60mL, 7 bottles, with
applicator in 1 carton
4 g/60mL, 28 bottles, dispensing in
1 carton

mesalamine

mesalamine
mesalamine
mesalamine
mesalamine
[Apriso]
mesalamine
[Apriso]
mesalamine
[Asacol]
mesalamine
[Canasa]
mesalamine
[Delzicol]
mesalamine
[Delzicol]
mesalamine
[Lialda]
mesalamine
[Pentasa]
mesalamine
[Rowasa]
mesalamine
[Rowasa]

Example: Data aggregated by RxDC drug name
Issuer or
TPA EIN
123456789
123456789
123456789
123456789
123456789
123456789
123456789
123456789

State
CA
CA
CA
CA
CA
CA
CA
CA

Market segment

RxDC Drug Name

RxDC Drug Code

Individual Market
Individual Market
Individual Market
Individual Market
Individual Market
Individual Market
Individual Market
Individual Market

mesalamine
mesalamine [Apriso]
mesalamine [Asacol]
mesalamine [Canasa]
mesalamine [Delzicol]
mesalamine [Lialda]
mesalamine [Pentasa]
mesalamine [Rowasa]

R00525820101000
R00525820101001
R00525820101002
R00525820101003
R00525820101004
R00525820101005
R00525820101006
R00525820101007

R005258201
01000
R005258201
01000
R005258201
01000
R005258201
01000
R005258201
01000
R005258201
01000
R005258201
01001
R005258201
01001
R005258201
01002
R005258201
01003
R005258201
01004
R005258201
01004
R005258201
01005
R005258201
01006
R005258201
01007
R005258201
01007

Number of paid
claims
9,744
3,904
5,642
2,145
6,015
8,983
198
1,703

32

Therapeutic classes
Location: D7 | Must not be blank
Therapeutic Class Max Length: 2,048 | Class Code Max Length: 100 characters
A therapeutic class is a group of drugs that have a similar mechanism of action or treat the same
condition. For example, mesalamine, balsalazide, olsalazine, and sulfasalazine are medications used to
reduce inflammation in the lining of the intestine. Therefore, they are assigned the same RxDC
therapeutic class name, Aminosalicylate. 13 If an NDC has more than one ingredient and those
ingredients belong to different therapeutic classes, the RxDC therapeutic class name is the combination
of the therapeutic classes. The therapeutic classes are listed alphabetically and separated from each
other using a pipe symbol (“|”), with a space on both sides of the pipe symbol. Ex: Therapeutic Class 1 |
Therapeutic Class 2.
Each RxDC therapeutic class has a unique RxDC class code. The RxDC names and codes are in the CMS
Drug and Therapeutic Class Crosswalk at https://www.cms.gov/CCIIO/Programs-and-Initiatives/OtherInsurance-Protections/Prescription-Drug-Data-Collection.
Example: Data aggregated by therapeutic class
Issuer or
TPA EIN
123456789
123456789
123456789
123456789
123456789
123456789

State
CA
CA
CA
CA
CA
CA

Market Segment
Individual market
Small group market
Large group market
Individual market
Small group market
Large group market

RxDC Therapeutic
Class
Corticosteroid
Corticosteroid
Corticosteroid
Anti-epileptic Agent
Anti-epileptic Agent
Anti-epileptic Agent

RxDC Class Code
E01755760101
E01755760101
E01755760101
E01757530101
E01757530101
E01757530101

Number of paid
claims
5,567
7,389
15,011
5,136
14,034
9,333

Where can I download the CMS Drug and Therapeutic Class Crosswalk File?
The crosswalk file is available on the CMS website at https://www.cms.gov/CCIIO/Programs-andInitiatives/Other-Insurance-Protections/Prescription-Drug-Data-Collection.

What if an NDC is missing from the CMS Drug and Therapeutic Class Crosswalk?
If the CMS crosswalk is missing an NDC for a prescription drug that was dispensed during the reference
year, you should assign the prescription drug a RxDC drug name using the naming method described in
Section 8.2. You should also assign a unique RxDC drug code. If the CMS crosswalk is missing the RxDC
therapeutic class name for an NDC, you should use the FDA Established Pharmacologic Class (EPC) (or
combination of EPCs) that you believe is most accurate. Provide information about the missing NDC or
missing therapeutic class in your Narrative Response.

8.3 Rx Utilization
Use the following definitions to report prescription drug utilization.
For the purposes of RxDC reporting, we generally group drugs by therapeutic class according to their FDA
Established Pharmacologic Class (EPC). See https://www.fda.gov/industry/structured-product-labelingresources/pharmacologic-class for more information on EPCs.
13

33

Number of paid claims
Location: D3, D4, D5, D7, D8 | Max decimals: 8
The number of claims paid for prescriptions filled during the reference year.

Number of members with a paid claim
Location: D3, D4, D5, D7, D8 | Integer
The number of members with at least one paid claim for a prescription filled during the reference year.

Total dosage units
Location: D3, D4, D5, D7, D8 | Max decimals: 8
The total number dosage units dispensed during the reference year. Dosage unit means the smallest
form in which a pharmaceutical product is administered or dispensed, such as a pill, tablet, capsule,
ampule, or measurement of grams or milliliters.

8.4 Rx Spending
Total spending and total cost sharing are net of prescription drug rebates, fees, and other remuneration.
The definitions in this section are the same as the definitions in Section 7.

Rx Total Spending
Location: D3, D4, D5, D6, D7, D8 | Max decimals: 8
Report allowed claims with dates of service during the reference year. Allowed claims are the total
payments made under the plan or policy to health care providers on behalf of members. Report claims
on a direct basis (that is, before reinsurance, unless specifically stated otherwise in these instructions).

•
•
•

Include in Rx Total
Spending
Payments by the plan,
issuer, or carrier
Cost sharing paid by
members
Claims liability,
including claims
incurred during the
reference year but not
paid or not reported
as of March 31 of the
year following the
reference year (such
as claims reported but
still in the process of
adjustment or
payment)

Subtract
•

•

•

Net payments from any federal
or state reinsurance or costsharing reduction arrangement
or program (see options below)
Prescription drug rebates, fees,
and other remuneration (In
other words, total spending is
net of prescription drug
rebates, fees, and other
remuneration.)
Manufacturer cost-sharing
assistance, to the extent known

Exclude
•

•

•

Ineligible claims, such as
duplicate claims, recovered
claims overpayments, thirdparty liabilities (e.g.,
coordination of benefits
claims), and any other claims
that are denied under the
policy’s or plan’s terms
Payments for services other
than medical care (e.g.,
medical management, quality
improvement, and fraud
detection and recovery
expenses)
Active life reserves (policy
reserves, contract reserves,
contingency reserves, or any
kind of reserves except
traditionally defined reserves
for claims incurred but not

34

Include in Rx Total
Spending

Subtract

Exclude

•

reported) or change in such
reserves
Charges or payments from
state or federal risk
adjustment programs

How do I account for net payments from federal or state reinsurance and cost-sharing reduction
programs when I report spending on prescription drugs?
Option 1
Determine the exact amount of net payments from federal or state reinsurance and cost-sharing
reduction programs attributable to specific drug claims, and use these amounts when reporting
spending at the drug level. If you choose Option 1, note the accounting method you used in the
narrative response.
Option 2
Use a reasonable method to allocate net payments from federal or state reinsurance and cost-sharing
reduction programs to the drug level. For example, you could allocate the amounts according to the
ratio of spending at the drug level divided by total spending on medical and pharmacy claims at the
aggregate level, either for all enrollees or for only the reinsurance-covered or CSR-eligible enrollees, as
applicable. If you choose Option 2, describe the allocation method you used in the narrative response
and explain why you think it is reasonable.
Option 3
You may choose to account for net payments from federal or state reinsurance and cost-sharing
reduction programs attributable to drug spending in the narrative response, rather than subtracting the
amounts from drug spending reported in data files D3 – D8. If you choose Option 3, the narrative
response must include the total amount of net payments from federal or state reinsurance and costsharing reduction programs, as applicable, allocated or attributable to prescription drugs, separately for
each state and market segment. The reporting entity that submits D3 – D8 can be different than the
reporting entity that submits the narrative response.

Rx Cost Sharing
Location: D3, D4, D5, D7, D8 | Max decimals: 8
Note: Report cost sharing as a stand-alone data element and include it when you report total spending.
Include in Rx Cost Sharing
• Deductibles, coinsurance,
and copays, including
amounts that may have
been paid through a health
savings or reimbursement
account

Subtract
• Cost sharing paid by a
member’s secondary insurance,
to the extent known
• Prescription drug rebates, fees,
and other remuneration that
are passed to members at the
point-of-sale, if not already

Exclude
• Cost sharing reductions the
issuer paid on behalf of the
member under federal or state
cost-sharing reduction programs
(include these amounts in total
spending but not in total cost
sharing)

35

Include in Rx Cost Sharing

Subtract
accounted for as reduced cost
sharing amounts paid by
members.

Exclude
• Premium
• Manufacturer cost-sharing
assistance

Rx Manufacturer cost-sharing assistance
Location: D3, D4, D5, D7, D8 | Max decimals: 8
Report manufacturer cost-sharing assistance amounts paid on behalf of members, such as coupons or
copay cards, to the extent the information is available.

Rx Amounts not applied to deductible or out-of-pocket maximum
Location: D6| Max decimals: 8
Report billed amounts that were (1) not applied to a member’s deductible or out-of-pocket maximum,
(2) not paid by the plan, issuer, or carrier, and (3) not included in Rx Total Spending.
Include:
•
•

Disallowed amounts for non-covered services or for prescription drugs not on a plan or coverage’s
formulary
Cost-sharing amounts not applied to the deductible or out-of-pocket maximum. For example, if
manufacturer cost-sharing assistance is not counted towards a member’s deductible or out-ofpocket maximum as part of an accumulator adjustment program, include it here.

8.5 Top Drug Lists
Exclude drugs covered under a non-pharmacy benefit when you create the four RxDC top drug tables. If
there are ties when you rank the top drugs, use the number of members with a paid claim as the tie
breaker. If there is still a tie, choose one of the other utilization or spending measures to break the tie.

D3 Top 50 Most Frequently Dispensed Brand Name Drugs
Use the following steps to create the Top 50 Most Frequent Brand Name Drugs table.
1. For each RxDC brand name drug, calculate the total number of paid claims in a state and market
by adding the number of paid claims for every NDC associated with the RxDC brand drug name.
− Only count paid claims for prescriptions filled during the reference year
− If you are reporting on behalf of multiple group health plans, include all of them when
calculating the total in the state and market for the issuer or TPA.
− CMS will indicate which drugs are considered brand name drugs in the CMS Drug and
Therapeutic Class Crosswalk File, or provide instructions for you to determine which drugs
are considered brand name drugs.
2. Rank the drugs in each state and market segment according to number of paid claims, sorted in
descending order. Using this ranking, identify the 50 brand name drugs with the highest number
of paid claims. Note: A rank value of 1 means the drug is the most frequently prescribed brand
name drug.

36

3. Create a table with the top 50 drugs and include a row for every state, market segment, and EIN
of the issuer or TPA. 14
− This means that there will be 50 rows for every state, market segment, and EIN
combination.
4. For each row, report the number of paid claims and the other utilization and spending variables
in the file layouts.

D4 Top 50 Most Costly Drugs
Use the following steps to create the Top 50 Most Costly Drugs table.
1. For each RxDC drug, calculate total spending, net of prescription drug rebates, fees, and other
remuneration, in the state and market segment by summing total spending for every NDC
associated with the RxDC drug name.
− Use the definition of Total Spending in Section 7.1 above.
− If you are reporting on behalf of multiple group health plans, include all of them when
calculating the total in the state and market for the issuer or TPA.
2. Rank the drugs in the state and market segment according to total spending, sorted in
descending order, and identify the 50 drugs with the greatest total spending. Note: A rank value
of 1 means that the drug has the greatest value for total spending.)
3. Create a table with the top 50 drugs and include a row for every state, market segment, and EIN
of the issuer or TPA.
− This means that there will be 50 rows for every state, market segment, and EIN
combination.
4. For each row, report total spending and the other utilization and spending variables in the file
layouts.

D5 Top 50 Drugs with the Greatest Increase in Spending
Exclude prescription drugs if they were not approved for marketing, or issued an Emergency Use
Authorization (EUA), by the Food and Drug Administration for the entire reference year and for the
entire calendar year immediately preceding the reference year. For example, if a drug was introduced in
2020, exclude the drug from D5 in the 2020 RxDC report and in the 2021 RxDC report. The CMS Drug
and Therapeutic Class Crosswalk will be updated to indicate the year in which a drug was first approved
for marketing or issued an EUA.
Include all plans and coverage in your calculations, even if the plan or coverage was not in effect for
both years. For example, if you are calculating the increase in spending from 2020 to 2021 and a plan
was only effective in 2020, you should include the plan in your 2020 total even though it isn’t in the
2021 total.
What if my client had a different reporting entity last year?
There are two reporting options:
• The previous reporting entity includes the client’s data in the prior year column of their report
(assuming they are still reporting on behalf of other clients); or
When we say the “EIN of the issuer or TPA”, this is a shorthand way of referring to the EIN of the relevant issuer,
TPA, carrier, or plan according to the Aggregation section above. Similarly, “market” or “market segment” includes
the FEHB line of business, where applicable.
14

37

•

You obtain prior year data from the previous reporting entity and include it in the prior year
column of your report.

Note: there will be a disconnect between the current year and prior year columns. (Because the set of
clients in the current year columns is different from the set of clients in the prior year column.)
Use the following steps to create D5 Top 50 Drugs with the Greatest Increase in Spending.
1. For each RxDC drug, calculate total spending, net of prescription drug rebates, fees, and other
price concessions, in the state and market segment by summing total spending for the reference
year for the NDCs associated with the RxDC drug name.
o Use the definition of Total Spending in Section 7.1 above.
o Only include NDCs if they were approved for marketing or issued an EUA for the entire
reference year and for the entire year prior to the reference year.
o If you are reporting on behalf of multiple group health plans, include all of them when
calculating the total in the state and market for the issuer or TPA.
2. For each RxDC drug, calculate total spending, net of prescription drug rebates, fees, and other
price concessions, in the state and market segment for the year prior to the reference year by
summing total spending for the NDCs associated with the RxDC drug name.
o Use the definition of Total Spending in Section 7.1 above.
o Only include NDCs if they were approved for marketing or issued an EUA for the entire
reference year and for the entire year prior to the reference year.
o If you are reporting on behalf of multiple group health plans, include all of them when
calculating the total in the state and market for the issuer or TPA.
3. For each RxDC drug, calculate the increase in total spending by subtracting total spending in the
state and market segment for the year prior to the reference year (the amount from Step 2)
from total spending in the state and market segment for the reference year (the amount from
Step 1).
o If spending on a drug increased from one year to the next, the difference will be a
positive number. If spending on a drug decreased from one year to the next, the
difference will be a negative number.
4. Rank the drugs in each state and market segment according to the increase in total spending
(the amount from Step 3), sorted in descending order. Identify the 50 drugs with the greatest
increase in total spending. A rank value of 1 means the drug has the greatest increase in total
spending.
o Use the dollar amount increase, not the percent increase.
5. Create a table with the top 50 drugs and include a row for every state, market segment, and EIN
of the issuer or TPA.
o This means that there will be 50 rows for every state, market segment, and EIN
combination.
6. For each row, report total spending in the reference year, total spending in the year prior to the
reference year, the increase in total spending, and the other utilization and spending variables in
the file layouts.

D8 Top 25 Drugs with the Greatest Amount of Rebates
Use the following steps to create the Top 25 by Rx Rebates table.

38

1. For each RxDC drug, calculate total rebates, fees, and other remuneration in the state and market
segment by summing total rebates, fees, and other remuneration for every NDC associated with the
RxDC drug name.
o Use the definition of Total Rebates, Fees, and Other Remuneration in Section 9.1 below.
o If Rx rebates, fees, and other remuneration cannot be measured at the NDC level, use a
reasonable method to allocate rebates, fees, and other remuneration to the NDC level. See
Section 9.2 below for more information about allocation methods.
2. Rank the drugs in the state and market segment according to total rebates, fees, and other
remuneration, sorted in descending order. Identify the 25 drugs with the greatest amount. A rank
value of 1 means the drug has the greatest amount of total rebates, fees, and other remuneration.
3. Create a table with the top 25 drugs and include a row for every state, market segment, and EIN of
the issuer or TPA.
o This means that there will be 25 rows for every state, market segment, and EIN
combination.
4. For each row, report prescription drug rebates, fees, and other remuneration, as well as the
utilization, spending, and other associated Rx rebate variables in the file layouts.

9 Rebates, Fees, and Other Remuneration
9.1 Definitions
Pharmacy benefit manager
Pharmacy benefit manager (PBM) generally means an entity that, either directly or through an
intermediary, acts as a price negotiator, manages the prescription drug benefits, or provides other
pharmacy benefit management services to the plan, issuer, or carrier. Pharmacy benefit management
services include processing and paying of prescription drug claims, performing drug utilization review,
processing prior authorization requests, adjudicating appeals or grievances related to the prescription
drug benefit, contracting with network pharmacies, designing formularies, and controlling the cost of
covered prescription drugs.

Rebates retained by PBMs
Location: D7, D8 | Max decimals: 8
Include:
• Manufacturer rebates received by PBMs and not passed through to any member or entity
• Amounts received directly from a manufacturer or indirectly from a pharmacy, wholesaler, or
other entity
• Include rebate amounts that are expected but have not yet been received if the PBM will retain
the expected amounts

Rebates retained by plans/issuers/carriers
Location: D7, D8 | Max decimals: 8
Include:
• Manufacturer rebates received by plans, issuers, or carriers and not passed through to any
member or entity
• Amounts received directly from a manufacturer or indirectly from a PBM, pharmacy, wholesaler,
or other entity

39

•
•

Rebate amounts that are expected but have not yet been received if the plan, issuer, or carrier
will retain the expected amounts
Rebate guarantee amounts. A rebate guarantee amount is a payment received from a PBM to
account for the difference between the rebate amount guaranteed by a PBM, as likely
delineated in the contract between the two parties, and the actual rebate amount received
from a drug manufacturer

Rebates passed to members at POS
Location: D7, D8 | Max decimals: 8
Include:
• Manufacturer rebates passed through (rather than retained by PBMs or plans/issuers/carriers)
to members at the point of sale (POS)
Exclude:
• Manufacturer cost-sharing assistance

Net transfer of other remuneration from manufacturers to plans/issuers/ carriers/PBMs
Location: D7, D8 | Max decimals: 8
Report net amounts. For example, if transfers from manufacturer to a PBM exceed transfers from the
PBM to manufacturer, report a positive number. If transfers from a PBM to the manufacturer exceed
transfers from the manufacturer to the PBM, report a negative number.
Include:
• Price concessions, fees, and other remuneration provided to a plan, issuer, carrier, or PBM,
directly or indirectly. For example, include the following amounts:
o Bona fide service fees
o Discounts
o Chargebacks
o Cash discounts
o Free goods contingent on a purchase agreement
o Up-front payments
o Coupons
o Goods in kind
o Free or reduced-price services
o Grants
o Other price concessions or similar benefits
• Fees and other remuneration that are expected but not yet transferred
Exclude:
• Any remuneration, coupons, or price concessions for which the full value is passed on to the
member

Net transfer of other remuneration from pharmacies to issuers/plans/carriers/PBMs
Location: D7, D8 | Max decimals: 8

40

Report the amounts described above (in the data element for the net transfer of other remuneration
from manufacturers to issuers, plans, carriers, and PBMs) except that the amount reported here should
be the net transfer from pharmacies, wholesalers, and other entities, rather than from manufacturers.
Report net amounts. For example, if transfers from pharmacies to a PBM exceed transfers from the PBM
to pharmacies, report a positive number; if transfers from a PBM to pharmacies exceed transfers from
pharmacies to the PBM, report a negative number.

Total rebates, fees, and other remuneration
Location: D7, D8 | Max decimals: 8
Sum of the previous five data elements.

Restated prior year rebates, fees, and other remuneration
Location: D7, D8 | Max decimals: 8
Restate total rebates and other remuneration from the prior reference year as of 3/31 of the calendar
year following the current reference year (that is, incurred in 12 months, paid or received in 27 months).
So, for example, in the 2021 RxDC report, there would be one column for total rebates for 2021 (as of
3/31/2022) and another column for restated rebates for 2020 (restated as of 3/31/2022). This field is
required starting with the RxDC report for the 2021 reference year.
What if my client had a different reporting entity last year?
As noted in Section 8.5, there are two reporting options:
• The previous reporting entity includes the client’s data in the prior year column of their
reference year report (assuming they are still reporting on behalf of other clients); or
• You obtain prior year data from the previous reporting entity and include it in prior year column
of your report.
Note: There will be a disconnect between the current year and prior year columns. (Because the set of
clients in the current year columns is different from the set of clients in the prior year column.)

Bona fide service fees
Location: D6 | Max decimals: 8
Bona fide service fees are fees that a manufacturer pays to a PBM that:
•

•

Represent fair market value for a bona fide, itemized service performed on behalf of the
manufacturer. These are services that the manufacturer would otherwise perform (or contract
for) in the absence of the service arrangement; and
Are not passed on in whole or in part to a client or customer of an entity, whether or not the
entity takes title to the drug.

PBM spread amounts
Location: D6 | Max decimals: 8
The PBM spread is the difference between the amount the plan, issuer, or carrier paid to the PBM and
the amount the PBM paid to manufacturers, wholesalers, pharmacies, or other vendors. For example, if
plans paid $250 to the PBM, and the PBM paid $200 to manufacturers, wholesalers, pharmacies, or
other vendors, the PBM spread amount would be $50.

41

Include:
• amounts for all drugs furnished through the PBM.
• amounts paid to retail, mail-order, and other pharmacies.
If a plan, issuer, or carrier uses pass-through pricing to pay PBMs, use zero for the PBM spread amount.
If a plan, issuer, or carrier uses lock-in pricing to pay PBMs, report the difference between the lock-in
price and the price ultimately received by the pharmacy.

9.2 Allocation Methods
Use a reasonable method to allocate rebates, fees, and other remuneration if they cannot be tied to a
specific prescription drug for a specific EIN, state, and market segment.
Here are examples of reasonable and unreasonable methods to allocate prescription drug rebates.
Method
Description
Reasonable?
Explanation
Based on
Allocate rebates received for multiple
Yes
Appropriately
dosage units drugs based on total dosage units for each
accounts for
drug as a percent of total drug spending
differences in a
for all the prescription drugs for which the
specific drug’s
rebate was received.
utilization across
plans and issuers.
Based on
Allocate rebates received for multiple
Yes
Approximates
total drug
drugs based on total drug spending for
differences in
spending
each drug as a percent of total drug
utilization and
spending for all the prescription drugs for
spending on rebate
which the rebate was received.
eligible drugs.
Based on
Rebates received for a specific drug are
Yes
Appropriately
billed rebate allocated to a plan, issuer, or carrier and
accounts for
amounts
11-digit NDC based on the rebate
differences in a
amounts billed to the pharmaceutical
specific drug’s
manufacturer for the specific plan, issuer,
utilization across
or carrier and drug as a percent of the
plans or issuers.
total rebate amount billed to the
pharmaceutical manufacturer for all the
PBM’s plans or issuers.
Based on
Rebate amounts received for multiple
Yes, but only if
Accounts for
plan’s brand drugs are allocated to a plan, issuer, or
the PBM
differences in
drug
carrier based on the total drug spend for
receives rebates utilization and
spending
drugs under the plan, issuer, or carrier as
only for brand
spending on rebatea percent of the total drug spend for
drugs.
eligible drugs across
brand drugs under all of the PBM’s plans
plans or issuers.
or issuers, and further to a prescription
drug based on the NDC-specific total drug
spend under the plan, issuer, or carrier as
a percent of the total drug spend for
brand drugs under the plan, issuer, or
carrier.
Based on
Rebates received for multiple drugs are
No
Does not sufficiently
enrollment
allocated to a plan, issuer, or carrier for
approximate

42

Method

Based on the
number of
paid claims

Description
prescription drug based on the number of
members enrolled in the plan, issuer, or
carrier as a percent of the total number of
members enrolled in all the PBM’s plans,
issuers or carriers.
Rebates received for multiple drugs are
allocated to a plan, issuer, or carrier for
prescription drugs based on the number
of claims under the plan, issuer, or carrier
as a percent of the total number of claims
received under all the PBM’s plans,
issuers or carriers. Thus, allocation is
based on the total number of claims for
all the drugs rather than the number of
claims received for each drug.

Reasonable?

No

Explanation
differences in
utilization and
spending on rebate
eligible drugs across
plans or issuers.
Does not sufficiently
approximate
differences in
utilization and
spending on rebate
eligible drugs across
plans or issuers.

Describe the method you used in the narrative response. If you used an allocation method other than
one of the methods described as reasonable in the table above, include enough detail for CMS to
evaluate whether the method is reasonable.
Also describe the methods you used to allocate fees or other remuneration in the narrative response.
Some allocation methods, such as allocation based on the number of paid claims, are considered
unreasonable for allocating rebates but might, based on the support that you provide in the narrative
response, be considered reasonable for allocating fees.

10 Narrative Response
Address the following topics in your narrative response. Save your narrative as a Word document or pdf
before uploading it into HIOS.

Employer size for self-funded plans
Did you use actual counts or estimates to determine the size of the employer for self-funded plans?
Describe your estimation method if you used estimates.

Net payments from federal or state reinsurance or cost-sharing reduction programs
If applicable, describe how you accounted for net payments from federal or state reinsurance and costsharing reduction programs. (See Section 8.4.)

Drugs missing from the CMS crosswalk
If the CMS crosswalk is missing an NDC for a drug that was prescribed during the reference year and
covered under the pharmacy benefit, provide the RxDC drug name and therapeutic class that you used.

Medical benefit drugs
Describe how you estimated the portion of bundled or alternative payment arrangements that can be
attributed to drugs covered under a medical benefit (as reported in D2). Describe allocation methods, if
applicable.

43

Prescription drug rebate descriptions
Describe the types of rebates, fees, and other remuneration that you included or excluded in the Rx
Totals, Rx Rebates by Therapeutic Class, and Rx Rebates for the Top 25 Drugs. Explain any negative
values for rebates, fees, or other remuneration.

Allocation methods for prescription drug rebates
Describe the methods you used to allocate prescription drug rebates, fees, and other remuneration. If
you used an allocation method other than one of the methods described as reasonable in the Section
9.2 above, your description must include enough detail for CMS to evaluate whether the method is
reasonable.

Impact of prescription drug rebates
Describe the impact of rebates, fees, and other remuneration on premium and out-of-pocket costs in
your narrative response. Provide as much detail as possible. Describe how and why the impact may vary
based on the market segment or for particular types of plans, such as high deductible health plans.
Describe the impact of prescription drug rebates on the tier assignment of prescription drugs in the
formulary, or the removal of generic equivalents from a formulary. If possible, provide a quantitative
estimate of the impact.

44

OMB control number: 0938-1407
Expiration Date: MM/DD/YYYY

11 Appendix A: File Layouts for the RxDC Report
11.1 Plan Lists
P1 Individual and Student Market Plan List
Note: Each row in P1 should have a unique combination of HIOS Plan ID and Plan Beginning Date
P1 Column Name
Field Type Instructions
HIOS Plan Name
String
Do not enter more than one value.
HIOS Plan ID
String
14-digit HIOS Plan ID. Ex: 12345NY1234567. Do not enter more than one value.
Note: Some grandfathered plans and student health plans currently don’t have HIOS
IDs. If a plan doesn’t have a HIOS Plan ID, follow the instructions in Section 4.2.
Plan Year Beginning Date
Date
MM/DD/YYYY
Do not enter more than one value.
Plan Year End Date
Date
MM/DD/YYYY
Do not enter more than one value.
Market Segment
String
Valid Values:
Individual market
Student market
Do not enter more than one value.
Members as of 12/31
Integer
The number of enrollees on the last day of the reference year. If a plan ended before
the last day of the reference year, enter 0.
PBM Name
String
If there is more than one value, separate them with a semicolon.
PBM EIN
String
9-digit EIN. Include leading zeros if your EIN is fewer than 9 digits. Do not use dashes.
Ex: 001234567. If there is more than one value, separate them with a semicolon.
Included in D1 Premium and Life
Integer
Valid Values:
Years?
0
(1= Yes; 0 = No)
1
Integer
Valid Values:
Included in D2 Spending by Category?
0
(1= Yes; 0 = No)
1
Paperwork Reduction Act Statement
According to the Paperwork Reduction Act of 1995 (PRA), 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 valid OMB control number for this information collection is 0938-1407. The
time required to complete this information collection is estimated to average 4,731 hours per response, 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.

P1 Column Name
Included in D3 Top 50 Most Frequent
Brand Drugs?
(1= Yes; 0 = No)
Included in D4 Top 50 Most Costly
Drugs?
(1= Yes; 0 = No)
Included in D5 Top 50 Drugs by
Spending Increase?
(1= Yes; 0 = No)
Included in D6 Rx Totals?
(1= Yes; 0 = No)
Included in D7 Rx Rebates by
Therapeutic Class?
(1= Yes; 0 = No)
Included in D8 Rx Rebates for the Top
25 Drugs?
(1= Yes; 0 = No)

Field Type
Integer
Integer
Integer
Integer
Integer
Integer

Instructions
Valid Values:
0
1
Valid Values:
0
1
Valid Values:
0
1
Valid Values:
0
1
Valid Values:
0
1
Valid Values:
0
1

P2 Group Health Plan List
Each row should have a unique combination of Group Health Plan Number, Plan Effective Date, and Plan Sponsor EIN.
P2 Column Name
Field Type Instructions
Group Health Plan Name
String
Do not include FEHB plans.
Group Health Plan Number
String
Enter a unique plan identification number. You can use the identification number in
your own database or any other numbering sequence as long as there is a unique plan
ID number for every plan. You may use the Form 5500 Plan Number.
HIOS Plan ID
String
Fully-insured small group plans only. Enter the 14-digit HIOS Plan ID(s). Do not use
dashes. Ex: 12345NY1234567. You may enter more than one value in the same cell. If
there is more than one value, separate them with a semicolon.
Form 5500 Plan Number
String
If applicable, enter the 3-digit plan number reported on the IRS Form 5500 filed with
the Department of Labor. If there is more than one value, separate them with a
semicolon.

46

P2 Column Name
States in which the plan offered

Field Type
String

Market Segment

String

Plan Beginning Date

Date

Plan End Date

Date

Members as of 12/31

Integer

Plan Sponsor Name

String

Plan Sponsor EIN

String

Issuer Name

String

Instructions
Enter the state(s) in which the plan or coverage is offered using 2-character state
postal code. 15 If there is more than one state, separate them with a semicolon. For
example: AL; AK; MA. If a plan is offered in every state and in DC, enter “National”. If a
plan is offered nationally and also in the territories, enter “National” as well as the 2character postal code for the territories, separated by a semicolon. For example:
National; PR; GU.
Valid Values:
Small group market
Large group market
SF small employer plans
SF large employer plans
For mixed-funded plans, enter both markets and separate them with a semicolon.
MM/DD/YYYY
If a plan has a non-calendar plan year and renews during the calendar year, use two
rows in the plan list file. (One row for the plan year that ended in the reference year
and another for the plan year that began during the reference year.)
MM/DD/YYYY
If a plan has a non-calendar plan year and renews during the calendar year, use two
rows in the plan list file. (One row for the plan year that ended in the reference year
and another for the plan year that began during the reference year.)
The number of members with coverage, including dependents, on the last day of the
reference year. If a plan ended before the last day of the reference year, enter 0.
Enter the plan sponsor or client name. If there is more than one value, separate them
with a semicolon.
Enter the 9-digit EIN. Include leading zeros if your EIN is fewer than 9 digits. Do not use
dashes. Ex: 001234567. If there is more than one value, separate them with a
semicolon.
If there is more than one value, separate them with a semicolon.

In these instructions, the term “State” includes the District of Columbia and the U.S. territories. For Federal Employee Health Benefit (FEHB) plans, you must
report data for the territories. For other plans, reporting on territories is optional.

15

47

P2 Column Name
Issuer EIN

Field Type
String

TPA Name
TPA EIN

String
String

PBM Name
PBM EIN

String
String

Included in D1 Premium and Life
Years?
(1= Yes; 0 = No)

Integer

Included in D2 Spending by Category?
(1= Yes; 0 = No)
Included in D3 Top 50 Most Frequent
Brand Drugs?
(1= Yes; 0 = No)
Included in D4 Top 50 Most Costly
Drugs?
(1= Yes; 0 = No)
Included in D5 Top 50 Drugs by
Spending Increase?
(1= Yes; 0 = No)
Included in D6 Rx Totals?
(1= Yes; 0 = No)
Included in D7 Rx Rebates by
Therapeutic Class?
(1= Yes; 0 = No)

Integer
Integer
Integer
Integer
Integer
Integer

Instructions
Enter the 9-digit EIN. Include leading zeros if your EIN is fewer than 9 digits. Do not use
dashes. Ex: 001234567. Ex: 001234567. If there is more than one value, separate them
with a semicolon.
If there is more than one value, separate them with a semicolon.
Enter the 9-digit EIN. Include leading zeros if your EIN is fewer than 9 digits. Do not use
dashes. Ex: 001234567. If there is more than one value, separate them with a
semicolon.
If there is more than one value, separate them with a semicolon.
Enter the 9-digit EIN. Include leading zeros if your EIN is fewer than 9 digits. Do not use
dashes. Ex: 001234567. If there is more than one value, separate them with a
semicolon.
Valid Values:
0
1
Valid Values:
0
1
Valid Values:
0
1
Valid Values:
0
1
Valid Values:
0
1
Valid Values:
0
1
Valid Values:
0
1

48

P2 Column Name
Included in D8 Rx Rebates for the Top
25 Drugs?
(1= Yes; 0 = No)

Field Type
Integer

Instructions
Valid Values:
0
1

P3 FEHB Plan List
Each row should have a unique combination of FEHB contract number, FEHB plan code, and plan beginning date
P3 Column Name
Field Type
Instructions
FEHB Plan Name
String
FEHB Contract Number
String
Enter the FEHB Contract ID.
FEHB Plan Code
String
Enter the two-digit FEHB plan code as it appears in the FEHB plan brochure. Separate
each two-digit plan code with a semicolon. Ex: 4A; 4B; 4E; 4L.
States in which the plan is offered
String
Enter the states and territories in which the plan is offered using the 2-character
postal code. If there is more than one state or territory, separate them with a
semicolon. For example: AL; AK; MA. If a plan is offered in every state and in DC,
enter “National”. If a plan is offered nationally and also in the territories, enter
“National” as well as the 2-character postal code for the territories, separated by a
semicolon. For example: National; PR; GU.
Plan Beginning Date
Date
MM/DD/YYYY
Do not enter more than one value.
Plan End Date
Date
MM/DD/YYYY
Do not enter more than one value.
Members as of 12/31
Integer
The number of FEHB covered individuals, including dependents, on the last day of
the reference year. If the plan ended before the last day of the reference year, enter
0.
FEHB Carrier Name
String
FEHB Carrier EIN
String
9-digit EIN. Include leading zeros if your EIN is fewer than 9 digits. Do not use dashes.
Ex: 001234567.
Affiliate Name
String
(If different from the FEHB carrier.)
If there is more than one value, separate them with a semicolon.
Affiliate EIN
String
(If different from the FEHB carrier.)

49

P3 Column Name

Field Type

TPA or Other Third-party Name

String

TPA or Other Third-party EIN

String

PBM Name

String

PBM EIN

String

Included in D1 Premium and Life
Years?
(1= Yes; 0 = No)

Integer

Included in D2 Spending by Category?
(1= Yes; 0 = No)
Included in D3 Top 50 Most Frequent
Brand Drugs?
(1= Yes; 0 = No)
Included in D4 Top 50 Most Costly
Drugs?
(1= Yes; 0 = No)
Included in D5 Top 50 Drugs by
Spending Increase?
(1= Yes; 0 = No)
Included in D6 Rx Totals?
(1= Yes; 0 = No)

Integer
Integer
Integer
Integer
Integer

Instructions
Enter the 9-digit EIN. Include leading zeros if your EIN is fewer than 9 digits. Do not
use dashes. Ex: 001234567. If there is more than one value, separate them with a
semicolon.
(If different from the FEHB carrier.)
If there is more than one value, separate them with a semicolon.
(If different from the FEHB carrier.)
Enter the 9-digit EIN. Include leading zeros if your EIN is fewer than 9 digits. Do not
use dashes. Ex: 001234567. If there is more than one value, separate them with a
semicolon.
(If different from the FEHB carrier.)
If there is more than one value, separate them with a semicolon.
(If different from the FEHB carrier.)
Enter the 9-digit EIN. Include leading zeros if your EIN is fewer than 9 digits. Do not
use dashes. Ex: 001234567. If there is more than one value, separate them with a
semicolon.
Valid Values:
0
1
Valid Values:
0
1
Valid Values:
0
1
Valid Values:
0
1
Valid Values:
0
1
Valid Values:
0
1

50

P3 Column Name
Included in D7 Rx Rebates by
Therapeutic Class?
(1= Yes; 0 = No)
Included in D8 Rx Rebates for the Top
25 Drugs?
(1= Yes; 0 = No)

Field Type
Integer
Integer

Instructions
Valid Values:
0
1
Valid Values:
0
1

11.2 Data Files
D1 Premium and Life Years
Each row in D1 must have a unique combination of EIN, state, and market segment.
D1 Column Name
Field Type
Instructions
Issuer or TPA Name
String
Enter the name of the issuer, TPA, FEHB carrier, or plan sponsor, as
applicable. Do not enter more than one value.
Issuer or TPA EIN
String
Enter the 9-digit EIN. Include leading zeros if your EIN has fewer than 9
digits. Do not use dashes. Ex: 001234567. Do not enter more than one
value.
State
String
Enter the 2-character state or territory postal code. Ex: NY. Do not enter
more than one value.
Market Segment
String
Valid Values:
Individual market
Student market
Small group market
Large group market
SF small employer plans
SF large employer plans
FEHB plans
Do not enter more than one value.
Average Monthly Premium Paid by Members
Numeric
Average Monthly Premium Paid by Employers
Numeric
Life Years
Numeric
Earned Premium
Numeric
For fully-insured plans.
Premium Equivalents
Numeric
For self-funded plans.
51

D1 Column Name
ASO/TPA Fees Paid (included in the Premium
Equivalents field)
Stop Loss Premium Paid (included in the
Premium Equivalents field)

Field Type
Numeric

Instructions
For self-funded plans.

Numeric

For self-funded plans.

D2 Spending by Category
Each row in D2 must have a unique combination of EIN, state, market segment, and spending category.
Field
D2 Column Name
Instructions
Type
Issuer or TPA Name
String
Enter the name of the issuer, TPA, FEHB carrier, or plan
sponsor, as applicable. Do not enter more than one value.
Issuer or TPA EIN
String
Enter the 9-digit EIN. Include leading zeros if your EIN has
fewer than 9 digits. Do not use dashes. Ex: 001234567. Do
not enter more than one value.
State
String
Enter the 2-character state postal code. Ex: NY. Do not enter
more than one value.
Market Segment
String
Valid Values:
Individual market
Student market
Small group market
Large group market
SF small employer plans
SF large employer plans
FEHB plans
Do not enter more than one value.
Spending Category
String
Valid Values:
Hospital
Primary Care
Specialty Care
Other medical costs and services
Known medical benefit drugs
Estimated medical benefit drugs
Do not enter more than one value.
52

Field
Instructions
Type
Total Spending
Numeric
Total Cost Sharing
Numeric
Amounts Not Applied to Deductible and/or Out-of-Pocket Maximum Numeric
D2 Column Name

D3 Top 50 Most Frequent Brand Drugs
Each row in D3 must have a unique combination of EIN, state, market segment, and drug code.
D3 Column Name
Field Type
Instructions
Issuer or TPA Name
String
Enter the name of the issuer, TPA, FEHB carrier, or plan sponsor, as
applicable. Do not enter more than one value.
Issuer or TPA EIN
String
Enter the 9-digit EIN. Include leading zeros if your EIN has fewer than 9
digits. Do not use dashes. Ex: 001234567. Do not enter more than one
value.
State
String
Enter the 2-character state postal code. Ex: NY. Do not enter more than
one value.
Market Segment
String
Valid Values:
Individual market
Student market
Small group market
Large group market
SF small employer plans
SF large employer plans
FEHB plans
Do not enter more than one value.
Drug Name
String
Enter the drug name from the CMS crosswalk file. Do not enter more than
one value.
Drug Code
String
Enter the drug code from the CMS crosswalk file. Do not use NDC. Do not
enter more than one value.
Frequency Rank
Integer
Valid Values: 1-50. Do not enter more than one value.
Number of Paid Claims
Integer
Number of Members with a Paid Claim
Integer
Number of Dosage Units
Numeric

53

D3 Column Name
Total Spending
Total Cost Sharing
Manufacturer Cost-Sharing Assistance

Field Type
Numeric
Numeric
Numeric

Instructions

D4 Top 50 Most Costly Drugs
Each row in D4 must have a unique combination of EIN, state, market segment, and drug code.
D4 Column Name
Field Type
Instructions
Issuer or TPA Name
String
Enter the name of the issuer, TPA, FEHB carrier, or plan sponsor, as
applicable. Do not enter more than one value.
Issuer or TPA EIN
String
Enter the 9-digit EIN. Include leading zeros if your EIN has fewer than 9
digits. Do not use dashes. Ex: 001234567. Do not enter more than one
value.
State
String
Enter the 2-character state postal code. Ex: NY. Do not enter more than
one value.
Market Segment
String
Valid Values:
Individual market
Student market
Small group market
Large group market
SF small employer plans
SF large employer plans
FEHB plans
Do not enter more than one value.
Drug Name
String
Enter the drug name from the CMS crosswalk file. Do not enter more than
one value.
Drug Code
String
Enter the drug code from the CMS crosswalk file. Do not use NDC. Do not
enter more than one value.
Cost Rank
Integer
Valid Values: 1-50. Do not enter more than one value.
Number of Paid Claims
Integer
Number of Members with a Paid Claim
Integer
Number of Dosage Units
Numeric
Total Spending
Numeric

54

D4 Column Name
Total Cost Sharing
Manufacturer Cost-Sharing Assistance

Field Type
Numeric
Numeric

Instructions

D5 Top 50 Drugs by Spending Increase
Each row in D5 must have a unique combination of EIN, state, market segment, and drug code.
D5 Column Name
Field Type
Instructions
Issuer or TPA Name
String
Enter the name of the issuer, TPA, FEHB carrier, or plan sponsor, as
applicable. Do not enter more than one value.
Issuer or TPA EIN
String
Enter the 9-digit EIN. Include leading zeros if your EIN has fewer than 9
digits. Do not use dashes. Ex: 001234567. Do not enter more than one
value.
State
String
Enter the 2-character state postal code. Ex: NY. Do not enter more than
one value.
Market Segment
String
Valid Values:
Individual market
Student market
Small group market
Large group market
SF small employer plans
SF large employer plans
FEHB plans
Do not enter more than one value.
Drug Name
String
Enter the drug name from the CMS crosswalk file. Do not enter more than
one value.
Drug Code
String
Enter the drug code from the CMS crosswalk file. Do not use NDC. Do not
enter more than one value.
Spending Increase Rank
Integer
Valid Values: 1-50. Do not enter more than one value.
Number of Paid Claims
Integer
Number of Members with a Paid Claim
Integer
Number of Dosage Units
Numeric
Total Spending
Numeric
Total Cost Sharing
Numeric

55

D5 Column Name
Manufacturer Cost-Sharing Assistance
Prior Year Number of Paid Claims
Prior Year Number of Members with a Paid
Claim
Prior Year Number of Dosage Units
Prior Year Total Spending
Prior Year Total Cost Sharing
Prior Year Manufacturer Cost-Sharing Assistance
Dollar Increase in Total Spending

Field Type
Numeric
Integer
Integer

Instructions

Numeric
Numeric
Numeric
Numeric
Numeric

D6 Rx Totals
Each row in D6 must have a unique combination of EIN, state, and market segment.
D6 Column Name
Field Type
Instructions
Issuer or TPA Name
String
Enter the name of the issuer, TPA, FEHB carrier, or plan sponsor, as
applicable. Do not enter more than one value.
Issuer or TPA EIN
String
Enter the 9-digit EIN. Include leading zeros if your EIN has fewer than 9
digits. Do not use dashes. Ex: 001234567. Do not enter more than one
value.
State
String
Enter the 2-character state postal code. Ex: NY. Do not enter more than
one value.
Market Segment
String
Valid Values:
Individual market
Student market
Small group market
Large group market
SF small employer plans
SF large employer plans
FEHB plans
Do not enter more than one value.
Total Rx Spending under Pharmacy Benefit
Numeric
Rx Amounts Not Applied to Deductible and/or
Numeric
Out-of-Pocket Maximum

56

D6 Column Name
Bona Fide Service Fees
PBM Spread Amounts
Total Rebates/Fees/Other Remuneration
Restated Prior Year Rebates/Fees/Other
Remuneration

Field Type
Numeric
Numeric
Numeric
Numeric

Instructions

D7 Rx Rebates by Therapeutic Class
Each row in D7 must have a unique combination of EIN, state, market segment, and therapeutic class code.
D7 Column Name
Field Type
Instructions
Issuer or TPA Name
String
Enter the name of the issuer, TPA, FEHB carrier, or plan sponsor, as
applicable. Do not enter more than one value.
Issuer or TPA EIN
String
Enter the 9-digit EIN. Include leading zeros if your EIN has fewer than 9
digits. Do not use dashes. Ex: 001234567. Do not enter more than one
value.
State
String
Enter the 2-character state postal code. Ex: NY. Do not enter more than
one value.
Market Segment
String
Valid Values:
Individual market
Student market
Small group market
Large group market
SF small employer plans
SF large employer plans
FEHB plans
Do not enter more than one value.
Therapeutic Class Name
String
Enter the therapeutic class name from the CMS crosswalk file. Do not enter
more than one value.
Therapeutic Class Code
String
Enter the therapeutic class code from the CMS crosswalk file. Do not enter
more than one value.
Number of Paid Claims
Integer
Number of Members with a Paid Claim
Integer

57

D7 Column Name
Number of Dosage Units
Total Spending
Total Cost Sharing
Manufacturer Cost-Sharing Assistance
Rebates Retained by PBM
Rebates Retained by Plan/Issuer/Carrier
Rebates Passed to Member at POS
Net Transfer of Fees and Other Remuneration
from Manufacturer to Plan/Issuer/Carrier
Net Transfer of Fees and Other Remuneration
from Pharmacy to Plan/Issuer/Carrier
Total Rebates/Fees/Other Remuneration
Restated Prior Year Rebates/Fees/Other
Remuneration

Field Type
Numeric
Numeric
Numeric
Numeric
Numeric
Numeric
Numeric
Numeric

Instructions

Numeric
Numeric
Numeric

D8 Rx Rebates for the Top 25 Drugs
Each row in D8 must have a unique combination of EIN, state, market segment, and drug code.
Field
D8 Column Name
Instructions
Type
Issuer or TPA Name
String
Enter the name of the issuer, TPA, FEHB carrier, or plan sponsor, as
applicable. Do not enter more than one value.
Issuer or TPA EIN
String
Enter the 9-digit EIN. Include leading zeros if your EIN has fewer than 9
digits. Do not use dashes. Ex: 001234567. Do not enter more than one
value.
State
String
2-character state postal code. Ex: NY. Do not enter more than one
value.
Market Segment
String
Valid Values:
Individual market
Student market
Small group market
Large group market

58

D8 Column Name

Field
Type

Drug Name

String

Drug Code

String

Rebate Rank
Number of Paid Claims
Number of Members with a Paid Claim
Number of Dosage Units
Total Spending
Total Cost Sharing
Manufacturer Cost-Sharing Assistance
Rebates Retained by PBM
Rebates Retained by Plan/Issuer/Carrier
Rebates Passed to Member at POS
Net Transfer of Fees and Other Remuneration from
Manufacturer to Plan/Issuer/Carrier
Net Transfer of Fees/Other Remuneration from
Pharmacy to Plan/Issuer/Carrier
Total Rebates/Fees/Other Remuneration
Restated Prior Year Rebates/Fees/Other Remuneration

Integer
Integer
Integer
Numeric
Numeric
Numeric
Numeric
Numeric
Numeric
Numeric
Numeric

Instructions
SF small employer plans
SF large employer plans
FEHB plans
Do not enter more than one value.
Enter the drug name from CMS crosswalk file. Do not enter more than
one value.
Enter the drug code from the CMS crosswalk. Do not use NDC. Do not
enter more than one value.
Valid Values: 1-25. Do not enter more than one value.

Numeric
Numeric
Numeric

59

11.3 File Requirements
What file format should I use?
You must use Comma Separated Value (CSV) format for your plan lists and data files. You can generate your own
CSV files or you can create them using the RxDC templates provided by CMS.
Where are the RxDC templates?
The RxDC templates are on the CMS website at https://www.cms.gov/CCIIO/Programs-and-Initiatives/OtherInsurance-Protections/Prescription-Drug-Data-Collection.

Follow these instructions when preparing your submission:
•
•
•
•
•
•
•

•

Your files must be in CSV format (If you use the Excel templates provided by CMS, save your files in CSV format before uploading them
into HIOS.)
The order of the columns in your file must exactly match the order of the columns in the file layouts.
The first row of your file should contain the column names. Your data should start on the second row.
You can use letters, numbers, and the following special characters in non-numeric fields: - (){}[] & ~ ! ; @ # $ % + =|.
Do not use commas or dollar signs in numeric fields. Only numbers and decimals are allowed.
Do not uses slashes (“/”) in alphanumeric fields. HIOS won’t accept text with slashes because data with slashes requires additional
security screening that would slow down processing time. The exception is that you can use slashes in the column headers and in date
fields.
You can use commas in a text field if there are quotation marks on both sides of the text. Ex: “Company ABC, Inc.”
o Excel will automatically insert the quotation marks for you when you save a file in CSV format. For example, you can enter
Company ABC, Inc in the template without quotation marks and Excel will convert it to “Company ABD, Inc” when you save it as
a CSV file. Without the quotation marks, HIOS won’t know whether a comma is part of a text string or is a delimiter between
columns.
Do not use more than 8 decimal places in numeric fields. Ex: 0.6666666666 should be rounded to 0.66666667.

60