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pdfDepartment of Health & Human Services
Centers for Medicare & Medicaid Services
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Baltimore, Maryland 21244-1850
Prescription Drug Data Collection (RxDC)
Reporting Instructions
Section 204 Data Submission Instructions
for the 2023 Reference Year
Last Updated April 2024
Primary Resources and Help Desk Information
RxDC Home Page
Download submission materials and user manuals at https://www.cms.gov/CCIIO/Programs-andInitiatives/Other-Insurance-Protections/Prescription-Drug-Data-Collection.
CMS Help Desk
If you still have questions after reading these instructions, contact our help desk at [email protected].
Include “RxDC” in the body of the email to expedite processing. You can typically expect a response within the
same day and a full resolution within 1-2 weeks. During periods of high volume, response times may be
significantly longer.
REGTAP
Sign up for emails, register for training webinars, and access additional training materials at
https://regtap.cms.gov/rxdc.php.
CMS Enterprise Portal
Submit your RxDC report in HIOS at https://portal.cms.gov/.
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Changes from the Previous Version
The most significant changes to the RxDC reporting instructions from the previous version include the following:
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•
•
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•
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•
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•
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Clarified that medical devices, nutritional supplements, and over the counter (OTC) drugs are excluded
from prescription drug lists (D3, D4, D5, D7, D8) unless the NDC for the product is on the CMS Drug and
Therapeutic Class Crosswalk (Section 8.1)
Simplified calculation of average monthly premium to use total annual premium divided by 12 instead of
the average monthly premium on a per-member basis (Section 6.1)
Simplified calculation of premium equivalents by removing restrictions on reporting on a cash basis and
using paid claims rather than incurred claims (Section 6.1)
Provided additional details about amounts that should be included or excluded from premium
equivalents (Section 6.1)
Updated instructions for populating the benefit carve-out field in P2 (Section 4.2)
Provided additional detail on reporting information in the prior year columns in D5 and the restated
rebate columns in D6, D7, and D8. Added corresponding instructions clarifying how to represent plans in
P2 when the plan contributes to the prior year and restated fields but not to the current year fields
(Sections 4.2, 8, and 9)
Provided instructions to reporting entities on how to report information on retained rebates when exact
amounts are unknown (Section 9.1)
Provided instructions on how to submit data when plan list or data files exceed the maximum allowable
size limit in the Health Insurance Oversight System (HIOS) (Section 3.6)
Announced enforcement of the aggregation restriction (Section 5.6)
Added a column to D6 to collect enrollment (Section 8.3)
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Table of Contents
Primary Resources and Help Desk Information............................................................................................ 2
Changes from the Previous Version ............................................................................................................. 3
1
2
3
4
5
Overview............................................................................................................................................... 6
1.1
What is the RxDC report? ............................................................................................................. 6
1.2
When is the deadline? .................................................................................................................. 6
1.3
Where can I get help?................................................................................................................... 6
1.4
Who must submit the RxDC report? ............................................................................................ 7
1.5
Applicability FAQs ......................................................................................................................... 8
Required Files ....................................................................................................................................... 8
2.1
Plan Lists and Data Files ............................................................................................................... 8
2.2
Narrative Response ...................................................................................................................... 9
2.3
Optional Supplemental Documents ............................................................................................. 9
Submission Process .............................................................................................................................. 9
3.1
Where do I submit my data? ........................................................................................................ 9
3.2
Can a vendor submit information on my behalf?......................................................................... 9
3.3
Can multiple vendors submit my data?...................................................................................... 10
3.4
Does every reporting entity need to submit a plan list? ............................................................ 10
3.5
Can a reporting entity create multiple submissions in HIOS? .................................................... 10
3.6
What if my file exceeds the file size limit in HIOS? .................................................................... 11
3.7
Can other reporting entities see my data?................................................................................. 11
3.8
How do I know if a reporting entity submitted my data? .......................................................... 11
Plan List Definitions ............................................................................................................................ 12
4.1
P1 Individual and Student Market Plan List................................................................................ 12
4.2
P2 Group Health Plan List ........................................................................................................... 14
4.3
P3 FEHB Plan List ........................................................................................................................ 21
Data Aggregation ................................................................................................................................ 23
5.1
Overview..................................................................................................................................... 23
5.2
Column Names ........................................................................................................................... 23
5.3
Market Segment Aggregation .................................................................................................... 24
5.4
State Aggregation ....................................................................................................................... 27
5.5
Company Aggregation ................................................................................................................ 27
5.6
Aggregation Restriction .............................................................................................................. 28
5.7
Examples of Aggregate Reporting .............................................................................................. 29
4
6
7
8
9
D1 Premium and Life-Years ................................................................................................................ 31
6.1
Definitions .................................................................................................................................. 31
6.2
D1 Example ................................................................................................................................. 35
D2 Spending by Category ................................................................................................................... 36
7.1
Definitions .................................................................................................................................. 37
7.2
Spending Categories ................................................................................................................... 39
7.3
D2 Example ................................................................................................................................. 43
Prescription Drug Reporting ............................................................................................................... 44
8.1
Prescription Drug Coverage ........................................................................................................ 44
8.2
Rx Utilization............................................................................................................................... 48
8.3
Rx Enrollment ............................................................................................................................. 48
8.4
Rx Spending ................................................................................................................................ 48
8.5
Top Drug Lists ............................................................................................................................. 50
Rebates, Fees, and Other Remuneration ........................................................................................... 54
9.1
Definitions .................................................................................................................................. 54
9.2
Allocation Methods .................................................................................................................... 56
10 Narrative Response ............................................................................................................................ 57
11 Appendix A: File Layouts for the RxDC Report ................................................................................... 59
11.1
Plan Lists ..................................................................................................................................... 59
11.2
Data Files .................................................................................................................................... 64
11.3
File Requirements ....................................................................................................................... 71
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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 (collectively, the Departments). In addition, the Director of the Office of Personnel Management
(OPM) requires Federal Employees Health Benefits (FEHB) carriers (carriers) to submit Section 204 data to HHS.
The Centers for Medicare & Medicaid Services (CMS) within HHS 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.
Is the RxDC report only for reporting information related to prescription drugs?
No. The RxDC report also collects information on total spending on health care services, including health care
premium, enrollment, and spending broken down by hospital costs, provider and clinical service costs for
primary and specialty care (separately), and other medical costs, including wellness services.
1.2 When is the deadline?
The deadline for the 2023 reference year report is June 1, 2024.
What is a Reference Year?
The reference year is the calendar year immediately preceding the calendar year in which the RxDC report is
due. The RxDC report for the 2023 reference year, which is due in 2024, should contain information based on
what happened in calendar year 2023.
1.3 Where can I get help?
CMS Website
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-Drug-DataCollection.
REGTAP
Sign up for email announcements and register for training webinars at Registration for Technical Assistance
Portal (REGTAP) at https://regtap.cms.gov/rxdc.php.
Help Desk
If you still have a question after reviewing the RxDC resources on the CMS website and in REGTAP, contact our
help desk at [email protected]. Include “RxDC” in the body of the email to expedite processing. You can
typically expect a response within the same day and a full resolution within 1-2 weeks. During periods of high
volume, response times may be significantly longer.
The CAA is available at https://www.congress.gov/116/bills/hr133/BILLS-116hr133enr.pdf. Section 204 starts on page
1737.
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You can also reach the help desk by phone at 1-855-267-1515. The help desk phone line is for general questions
about CMS programs. If you have a question that is specific to RxDC, the help desk will ask for your email
address and create a ticket so that an RxDC specialist can respond by email.
Help Desk Tips
You can help us respond to help desk tickets faster if you:
• Contact us by email rather than phone.
• Include “RxDC” in the body of the email.
• Do not email or call for status updates on an existing ticket.
• Do not create multiple tickets on the same topic.
• If you figure out the answer to your question before you hear back from the help desk, respond to your
ticket confirmation email and say: “I no longer need help on this topic. Please close this ticket.”
• If you have a follow-up question after we respond to your inquiry, reply to our latest email to ask the
follow-up question. However, if we have answered your question, please do not reply only to thank us
(while we appreciate it, if you reply to the email, it re-opens the ticket).
1.4 Who must submit the RxDC report?
Required to Submit
• Health insurance issuers offering group market
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 Group health plans subject to Employee
Retirement Income Security Act of 1974
(ERISA)
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 FEHB plans
Not Required to Submit
• Account-based plans, such as health
reimbursement arrangements (HRAs)
• Excepted benefits 2 including but not limited to:
o Limited-scope standalone dental and vision
plans
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
• Retiree-only plans 3
• Plans maintained outside of the U.S. primarily for
the benefit of persons substantially all of whom are
nonresident aliens 4
These requirements apply regardless of whether a plan is considered a grandfathered or grandmothered health
plan. 5
Public Health Service Act section 2722(b) and (c), Employee Retirement Income Security Act section 732, and Internal
Revenue Code section 9831.
3
A retiree-only plan is a plan that covers retirees with fewer than two participants who are active employees.
4
An alien is any individual who is not a U.S. citizen or U.S. national. A nonresident alien is an alien who has not passed the
green card test or the substantial presence test.
5
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
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Plans, issuers, and carriers may have vendors submit the RxDC report on their behalf. See Section 3 for more
information about vendor submissions.
1.5 Applicability FAQs
Below are common questions about who must submit the RxDC report.
My plan has only medical benefits and does not have pharmacy benefits. Do I have to submit the RxDC report?
Yes. Unless your plan is exempt from the Section 204 reporting requirements (see Section 1.4 above), you (or
your reporting entity, as defined in Section 3.2) must submit a plan list (P1, P2, or P3), data files D1 and D2, and
a narrative response to report the required information about the plan’s medical benefit. You do not need to
submit data files D3 – D8 if your plan does not have pharmacy benefits.
Does RxDC apply to U.S. territories?
Yes. Plans, issuers, and carriers must report RxDC data for all 50 states, the District of Columbia (D.C.), and the
U.S. territories. In these instructions, the term “State” includes all 50 states, D.C., and the territories.
What if my company went out of business? Do I still need to report?
For self-funded terminated plans, reporting entities may choose to include or exclude the business associated
with the terminated plan. For fully-insured terminated plans, reporting entities should include the business
associated with the terminated plan.
Issuers that go into liquidation during or after the reference year are still subject to the RxDC reporting
requirements and must submit data for the portion of the reference year before the liquidation was completed.
If a reporting entity, such as a Pharmacy Benefit Manager (PBM), submits on behalf of an issuer, the issuer
should ensure that the vendor includes data for the portion of the reference year before the issuer went into
liquidation.
2 Required Files
Plans, issuers, and carriers must submit (or have submitted on their behalf) a plan list (P1, P2, and/or P3), eight
data files (D1-D8), and a narrative response. A submission can include more than one plan list file type but
cannot contain more than one file of the same type. For example, you can upload P1 and P2 in the same
submission, but not two versions of P2. Similarly, you cannot upload two versions of the same data file type or
two versions of the narrative response in the same submission.
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
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
action with respect to certain market requirements. See Bulletin: Extended Non-Enforcement of Affordable Care ActCompliance With Respect to Certain Policies, available at https://www.cms.gov/files/document/extension-limited-nonenforcement-policy-through-calendar-year-2023-and-later-benefit-years.pdf.
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Subject
Purpose
Plan Lists
The plan list identifies the plans in a
submission. The plan list also collects 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 group
health plans that are not FEHB plans
• P3 is required for FEHB plans
File Format
Comma Separated Values (CSV)
Data Files
The data files collect premium and
spending information at an aggregate level.
D1 – D8 are required for plans with
medical and pharmacy benefits
• D1 and D2 are required for plans with
only medical benefits
• D1 and D3 – D8 are required for plans
with pharmacy benefits only
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 and the data dictionary 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. 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.
2.3 Optional Supplemental Documents
If you want to provide additional information about your submission, the system will allow you to upload up to
30 supplemental documents. The supplemental files must be in PDF, Word, Excel, or CSV format.
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 (TPA), PBM, 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 for how to create your CMS Enterprise Portal account and access HIOS are in the RxDC HIOS
Access Guide.
The instructions for using the RxDC module are in the RxDC HIOS Module User Manual.
3.2 Can a vendor submit information on my behalf?
Yes. Plans, issuers, and carriers can contract with issuers, TPAs, Administrative Services Only providers (ASOs),
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.
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What is a reporting entity?
An entity that submits some or all required information with respect to a plan, issuer, or carrier 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 selffunded 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.
Can multiple reporting entities upload files into the same HIOS submission?
No. Each reporting entity must create its own submission in HIOS. For example, if an issuer is submitting D1 and
D2 and a PBM is submitting D3 – D8 on behalf of the same plan, the issuer and the PBM must create separate
submissions with different submission IDs. In this example, the issuer’s submission would contain P2, D1, and
D2. The PBM’s submission would contain P2 and D3 – D8. The issuer and the PBM both have the opportunity to
upload a narrative response and/or supplemental files.
Can multiple vendors submit the same data file type?
Plans, issuers, carriers, and their reporting entities are encouraged to work together to submit only one data file
of each data file type for the same plan, issuer, or carrier. For example, if one reporting entity is responsible for
only some of the fields in a data file, it might 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.
However, if entities are unwilling or unable to work together, more than one reporting entity may submit the
same type of data file on behalf of the same plan, issuer, or carrier. For example, if a plan has two issuers, one
for behavioral health benefits and another for other medical benefits, then both issuers can submit D2 on behalf
of the plan. The first issuer’s D2 would include the plan’s data related to behavioral health benefits. The second
issuer’s D2 would include the plan’s data related to other medical benefits.
Similarly, if a plan, issuer, or carrier changes vendors during the reference year (such as changing a TPA or PBM),
it’s acceptable for the previous vendor to report the data from the period prior to the change, and the new
vendor to report the data from the period beginning on the date the change was effective. Alternatively, the
previous vendor may provide the data to the new vendor and the new vendor would report the entire year of
data.
3.4 Does every reporting entity need to submit a plan list?
Yes. Each reporting entity must submit a plan list file (P1, P2, and/or P3) so that CMS will know which plan’s data
are included in the submission and when multiple entities are reporting for the same plan. If you know which
reporting entity will be reporting on behalf of a plan, enter that reporting entity’s company name and Employer
Identification Number (EIN) in the appropriate columns in the plan list file. (See Plan List Definitions in Section
4.) CMS will use this information to streamline the reconciliation process when there are multiple reporting
entities.
Note: Multiple reporting entities may upload different narrative responses on behalf of the same plan, issuer, or
carrier. Also, a reporting entity may submit a data file without a narrative response, or a narrative response
without a data file. However, each reporting entity must submit a plan list.
3.5 Can a reporting entity create multiple submissions in HIOS?
A reporting entity may make multiple submissions in HIOS if the content of the submissions is mutually
exclusive. That is, if a reporting entity creates multiple submissions, each plan in the plan lists and data files
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must be included in only one of the submissions. If you accidentally create multiple submissions with
overlapping content, please refer to the RxDC HIOS Manual User Guide for instructions on editing and deleting
submissions.
3.6 What if my file exceeds the file size limit in HIOS?
The HIOS file size limit is 200 megabytes per file. If your file exceeds the file size limit, use one or both of the
following methods to reduce the size of your file.
Option 1: Break up your files by market segment and aggregation state
If your files are too large, you may break them up into multiple smaller files by market segment (or groupings of
market segments) and submit them separately in HIOS. If the files are still too large after breaking them up by
market segment, you may break them up by aggregation state (or groupings of aggregation states). If you
choose this method, every file in your submission should be broken up in the same way. (See Sections 5.3 and
5.4 for more information on market segment and aggregation state.)
Option 2 – Leave drug name and therapeutic class name blank
If data file D7 is too large, you may leave therapeutic class name blank as long as therapeutic class code is
populated with a class code from the CMS crosswalk. (See Section 8.1 for more information on the CMS
crosswalk.) If data files D3, D4, D5 and/or D7 are too large, you may leave drug name blank as long as the drug
code field is populated with a drug code from the CMS crosswalk.
File
D3 Top 50 Most Frequent Brand Drugs
D4 Top 50 Most Costly Drugs
D5 Top 50 Drugs by Spending Increase
D7 Rx Rebates by Therapeutic Class
D8 Rx Rebates for the Top 25 Drugs
Text field that may be blank
to reduce file size
• Drug Name
• Drug Name
• Drug Name
• Therapeutic Class Name
• Drug Name
•
•
•
•
•
Corresponding fields that
must NOT be blank
Drug Code
Drug Code
Drug Code
Therapeutic Class Code
Drug Code
3.7 Can other reporting entities see my data?
No. 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.
Further, a reporting entity cannot see whether another reporting entity submitted a file.
Note: If a reporting entity has more than one employee with an RxDC Submitter role in HIOS, those employees
will be able to view and edit each other’s RxDC submissions.
3.8 How do I know if a reporting entity submitted my data?
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.
What should I do if my insurance company or TPA sent me an RxDC survey?
Some insurance companies (issuers) and vendors (such as TPAs, ASOs, PBMs, or brokers) may send surveys or
otherwise request information from their clients so that the issuer or vendor can complete plan list P2 and data
file D1 on behalf of their clients. The survey is not from CMS and is generally a different document than what
issuers or vendors submit to CMS as the federal RxDC report. If your issuer or vendor does not submit P2 and D1
(or other required files) to CMS on your behalf, then you (or another reporting entity) must submit P2 and D1
directly to CMS.
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If you have a question about the logistics of a survey that you receive from an issuer or vendor, such as how to
submit or edit your response or the survey deadline, you must contact your issuer or vendor. CMS is not
involved in any outside survey.
4 Plan List Definitions
Use the following definitions when you fill out your plan lists.
Punctuation
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 alphanumeric fields if the string is enclosed by double-quotation marks as text
qualifiers. (Example: “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.
4.1 P1 Individual and Student Market Plan List
Note: Plan list P1 is only applicable to insurance companies that file the Medical Loss Ratio report, and to
reporting entities, such as PBMs, that submit data on behalf of insurance companies. Do not fill out P1 if you are
a group health plan.
HIOS Plan Name
Location: P1 Column A | 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. Do not use slashes.
HIOS Plan ID
Location: P1 Column B | Max length: 25 characters | Must not be blank
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 an individual or
student market plan does not have a HIOS Plan ID, create a unique 14-character plan ID as follows:
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
All insurance companies should already have a HIOS Issuer ID, even if they only offer plans that don’t have a
HIOS Plan ID. Contact the help desk if you are an insurance company and you do not know your HIOS Issuer ID.
(Do not contact the help desk for a HIOS Issuer ID or HIOS Plan ID if you are not an insurance company.)
Plan Year Beginning and End Dates
Location: P1 Columns C and D | Format: MM/DD/YYYY
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Enter the plan year beginning and end dates. If an individual or student market plan doesn’t have a designated
plan year, you may enter the first and last day of the reference year.
Note: If a plan is included on the plan list solely because it contributed to prior year columns (D5) or the restated
rebate column (D6, D7, D8) but didn’t contribute to fields for the current reference year, you have the option of
including the plan in the plan list. If you choose to include the prior year plan in the plan list, report 01/01/2023
and 01/02/2023 as the plan year beginning and end dates, respectively, or leave both values blank. (HIOS will
reject submissions if a plan year end date is in the year prior to the reference year.)
See Sections 4.2 and 4.3 for the instructions for group health plans and FEHB plans, respectively.
Market Segment
Location: P1 Column E | Max length: 100 characters | Must not be blank
In P1, enter “Individual market” for individual market plans that are not student market plans. Enter “student
market” for plans in the student market. Do not enter more than one market segment in the same cell. This field
is not case sensitive, but you must use exact spelling.
See Sections 4.2 and 4.3 for the instructions for group health plans and FEHB plans, respectively.
Members as of 12/31
Location: P1 Column F| Max decimal places: 0
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.
In the individual and student market, the term “member” means a person who has health coverage through an
individual market or student market plan. The term includes policyholders and dependents.
See Sections 4.2 and 4.3 for the instructions for group health plans and FEHB plans, respectively.
PBM Name
Location: P1 Column G | Max Length 2,048 characters
Enter the PBM name. Do not use slashes. If there is more than one PBM, separate the names with a semicolon.
If a plan doesn’t have a PBM, leave the cell blank.
See Section 4.2 for the definition of a PBM.
PBM EIN
Location: P1 Column H | Format: 9 digits
Enter the PBM 9-digit EIN without dashes. (Example: 012345678.) If there is more than one PBM, separate the
PBMs with a semicolon. If a plan doesn’t have a PBM, leave the cell blank.
Included in D1 – D8
Location: P1 Columns I – P | Valid Values: 0 or 1
Enter 1 if a plan’s data is included in the respective data file in your submission. Enter 0 if the plan’s data is not
included in the respective data file in your submission. Do NOT enter 1 if a different entity is submitting a data
file. For example, if an issuer is submitting D1 and D2 on behalf of a plan and a PBM is submitting D3 – D8, the
issuer should enter 1 in “Included in D1” and “Included in D2” and enter 0 for “Included in D3” through
“Included in D8.” The PBM should enter 0 in “Included in D1” and “Included in D2” and enter 1 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.
13
Example:
An issuer is submitting on behalf of three plans. For two of those plans, the issuer is submitting D1 and D2 only
and the PBM is submitting D3 – D8. For the third plan, the issuer is submitting all 8 data files D1 – D8.
P1 Submitted by the Issuer
HIOS Plan
Name
Plan A
Plan B
Plan C
…
…
…
…
Included in
D1
Premium
and Life
Years?
Included in
D2
Spending
by
Category?
Included
in D3 Top
50 Most
Frequent
Brand
Drugs?
Included
in D4 Top
50 Most
Costly
Drugs?
Included in
D5 Top 50
Drugs by
Spending
Increase?
1
1
1
1
1
1
0
0
1
0
0
1
0
0
1
Included in
D1
Premium
and Life
Years?
Included in
D2
Spending
by
Category?
Included
in D3 Top
50 Most
Frequent
Brand
Drugs?
Included
in D4 Top
50 Most
Costly
Drugs?
Included in
D5 Top 50
Drugs by
Spending
Increase?
0
0
0
0
1
1
1
1
1
1
P1 Submitted by the PBM
HIOS Plan
Name
Plan A
Plan B
…
…
…
Included
in D6 Rx
Totals?
0
0
1
Included
in D6 Rx
Totals?
1
1
Included in
D7 Rx
Rebates by
Therapeutic
Class?
Included in
D8 Rx
Rebates for
the Top 25
Drugs?
0
0
1
0
0
1
Included in
D7 Rx
Rebates by
Therapeutic
Class?
Included in
D8 Rx
Rebates for
the Top 25
Drugs?
1
1
1
1
4.2 P2 Group Health Plan List
If a group health plan offers multiple benefit options, you may combine them into one row in the plan list or use
multiple rows. It’s up to you.
Group Health Plan Name
Location: P2 Column A | Max length: 512 characters | Must not be blank
Enter the group health plan name. Do not use slashes.
Group Health Plan Number
Location: P2 Column B | 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 plan number from your accounting system, the Form 5500 Plan Number 6 (if a Form 5500 is filed for the
plan), the plan sponsor EIN (if the plan sponsor only has one plan), or create a new identification number to
enumerate the plans in the plan list.
If you use a Form 5500 Plan Number as the Group Health Plan Number, 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.
If you use the plan sponsor EIN as the Group Health Plan Number, you must also enter the plan sponsor EIN in
the Plan Sponsor EIN column. That is, the plan sponsor EIN would be in the Group Health Plan Number column
and the Plan Sponsor EIN column.
For more information on the Form 5500 Plan Number, see the Form 5500 Instructions at
https://www.dol.gov/sites/dolgov/files/EBSA/employers-and-advisers/plan-administration-and-compliance/reporting-andfiling/form-5500/2023-sf-instructions.pdf.
6
14
When multiple entities submit information about the same plan, do they need to use the same plan number?
Multiple entities submitting information about the same plan are encouraged to use the same plan name and
plan number to help CMS reconcile submissions.
Note: Entities must use the same plan sponsor EIN in the Plan Sponsor EIN column when reporting on behalf of
the same plan, regardless of whether they use the same plan name and number.
Carve-Out Description
Location: P2 Column C | Max length: 2,048 characters
This field is required when a reporting entity is submitting data for a carved-out benefit. An example of a carveout benefit is a benefit administered, offered, or insured by an entity that is different than the entity that
administers, offers, or insures the majority of the plan’s other benefits.
Enter one of the following:
•
•
•
•
•
•
Pharmacy only
Behavioral health only
Fertility only
Specialty drugs only
Hospital only
Other
Plans without pharmacy benefits
If you are submitting on behalf of a plan that, to the best of your knowledge, does not cover pharmacy benefits
(and therefore a PBM or other reporting entity will not be submitting D3 – D8 for that plan), enter “This plan
does not include pharmacy benefits.” (Do not include the quotation marks.) This will let CMS know that we
shouldn’t expect D3 – D8 for that plan.
If you are submitting data regarding a plan’s medical benefit and, to the best of your knowledge, a different
reporting entity will submit data regarding the plan’s pharmacy benefit, enter “Medical only.” (Do not include
the quotation marks.) This will let CMS know that we should expect another reporting entity to submit D3 – D8
for that plan.
If you don’t know whether a plan has a pharmacy benefit or whether another reporting entity is expected to
report on a plan’s pharmacy benefit, you may leave this field blank.
Note: You may leave this field blank if you are reporting information about the carve-out benefit and
information about the majority of the plan’s other benefits, and you are using one row in the plan list that
represents the main plan and the carve-out (or two rows for non-calendar year plans).
Form 5500 Plan Number
Location: P2 Column D | Max length: 1,024 characters
If a group health plan submits a Form 5500 to the Department of Labor, enter the 3-digit Form 5500 plan
number (self-assigned by the filer in accordance with Form 5500 Instructions). If there is more than one value,
separate them with a semicolon.
If you don’t have a Form 5500 Plan Number, leave this field blank. If you’re not sure if you have a Form 5500
Plan Number, you can look it up using the Form 5500 search tool on the Department of Labor website at
https://www.efast.dol.gov/5500search. If the reporting entity does not obtain this information from the plan,
the reporting entity may leave this field blank.
15
States in which the plan is offered
Location: P2 Column E | Max length: 200 characters
Enter the states and territories in which the plan or coverage is offered using two-character state postal code. If
there is more than one state or territory, separate them with a semicolon. (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 one or more
territories, enter “National” as well as the two-character postal code for the applicable territories, separated by
a semicolon. (Example: National; PR; GU.)
For purposes of RxDC reporting, a plan is considered “offered” in a state if a person living or working in that
state would be eligible to obtain coverage under the plan. Self-funded plans may enter “National” if a person
living or working in any state would be eligible to obtain coverage under the plan.
Note 1: “States in which the plan is offered” in the plan lists (P2, P3) is not the same thing as “Aggregation State”
in the aggregate data files (D1 – D8). See Section 5.4 for more information on state aggregation.
Note 2: If multiple vendors submit on behalf of the same plan, issuer, or carrier, only one of them is required to
report the states in which the plan is offered.
Market Segment
Location: P2 Column F | Max length: 512 characters | Must not be blank
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
semicolon. (Example: Large group market; SF large employer plans.)
See Section 5.3 for more information on market segments and how to determine whether an employer is a small
employer or a large employer.
Note: P2 is the only place where you can put more than one market segment in a single cell. Do not enter more
than one value for market segment in data files D1 – D8.
Plan Year Beginning and End Dates
Location: P2 Columns G and H | Format: MM/DD/YYYY
Enter the actual beginning and end dates of the plan year, even if they fell outside of the reference year.
The plan year may be the year in the plan document of a group health plan, the deductible or limit year used
under the plan, or the policy year.
Note 1: If a plan is included on the plan list solely because it contributed to prior year columns (D5) or the
restated rebate column (D6, D7, D8) but didn’t contribute to fields for the current reference year, you have the
option of including the plan in the plan list. If you choose to include the prior year plan in the plan list, report
01/01/2023 and 01/02/2023 as the plan year beginning and end dates, respectively, or leave both values blank.
(HIOS will reject submissions if a plan year end date is in the year prior to the reference year.)
Note 2: When multiple vendors submit on behalf of the same plan, at least one vendor must enter the beginning
and end dates of the plan year. The other vendors may enter the beginning and end dates of the plan year, or
the first and last day of the portion of the reference year for which they are submitting data.
How do I fill out the plan list for plans with non-calendar plan years?
Suppose for example that the plan year is July 1, 2022 through June 30, 2023. Enter 07/01/2022 for the
beginning date and 06/30/2023 for the end date in the 2023 RxDC report. Because the plan year ended before
the end of the reference year, enter 0 for the number of members as of 12/31/2023 in the 2023 RxDC report.
16
Similarly, if the plan year is July 1, 2023 through June 30, 2024, enter 07/01/2023 for the beginning date and
06/30/2024 for the end date in the 2023 RxDC report. Enter the actual number of members as of 12/31/2023 in
the 2023 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 6/30/2023 and another for the plan year that began on 7/1/2023.
Example: Non-calendar year plan in the 2023 RxDC report.
Group
Plan Year
Group Health Plan
Market
Health Plan
Beginning
Name
Segment
Number
Date
Jane’s Furniture Health
Small group
501
07/01/2022
and Welfare Plan
market
Jane’s Furniture Health
Small group
501
07/01/2023
and Welfare Plan
market
Plan Year End
Date
Members as of
12/31 of the
reference year
06/30/2023
0
06/30/2024
27
Note: In the data files (as opposed to the plan lists), the reporting entity would include only the data related to
the 2023 calendar year (e.g., the last six months of the “old” plan and the first six months of the “new” plan).
Members as of 12/31
Location: P2 Column I | Max decimal places: 0
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. Retirees and COBRA participants, including their dependents, also are
considered members if they are covered by a plan that is not a retiree-only plan.
Note: In the plan lists, report members as of 12/31 of the reference year. In data file D1, report the average
number of members during the reference year, which is called life-years.
Plan Sponsor Name
Location: P2 Column J | Max length: 2,048 characters
The term plan sponsor means:
•
The employer, for an employee benefit plan that a single employer established or maintains. Note: A
plan of a controlled group of corporations that is treated as a single employer generally is a singleemployer plan and should enter the name of the parent corporation or other member of the controlled
group considered the sponsor; 7
•
The employee organization (such as a labor union) in the case of a plan of an employee organization; or
If companies are in the same controlled group but have different EINs and file separate Form 5500s, the companies may,
but do not have to, submit separate RxDC reports.
7
17
•
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. 8
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. (Alternatively, you may use a separate row in
the plan list for each plan sponsor.)
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, you may enter the name of a participating employer.
Use the same name in future RxDC reports unless there is a change in sponsorship.
In HIOS, you may upload a supplemental document with 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 Column K | Max length: 2,048 characters | Must not be blank
Enter the 9-digit employer EIN assigned to the plan sponsor. (Example: 012345678.) Do not use dashes. 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.
What if I don’t know the plan sponsor EIN?
You must report the plan sponsor EIN. If you don’t know the EIN, you must obtain the information from the plan
sponsor. 9 CMS uses the plan sponsor EIN to reconcile submissions made by multiple reporting entities on behalf
of the same plan.
Note: HIOS has been updated to accept EINs with more than one leading zero.
Issuer Name
Location: P2 Column L | Max Length: 2,048 characters
Only required if an insurance company or stop-loss carrier is one of the plan’s reporting entities.
Enter the issuer name. Do not use slashes. If there is more than one issuer, enter both in the same cell separated
by a semicolon.
An issuer refers to the insurance company, service, or organization (including an HMO) with which a fullyinsured group health plan has a contract or policy for insurance coverage. If the plan is not insured, leave the cell
blank.
Self-funded plans:
• For self-funded plans with stop-loss coverage, enter the name of the stop-loss carrier.
• For self-funded plans that use an issuer as a TPA or ASO provider, do NOT enter the name of the issuer
here. Instead, enter the name of the issuer providing the TPA/ASO services in the “TPA Name” column.
Public Health Service Act section 2791(d)(13), referencing Employee Retirement Income Security Act section 3(16)(B).
If a plan sponsor files the Form 5500 report with the Department of Labor, you may use the public Form 5500 data sets or
search tool to obtain a plan sponsor’s EIN in lieu of collecting the EIN from the plan sponsor. The Form 5500 datasets are
available at https://www.dol.gov/agencies/ebsa/about-ebsa/our-activities/public-disclosure/foia/form-5500-datasets. The
search tool is available https://www.efast.dol.gov/5500search/. If you are unable to obtain the EIN using the publicly
available Form 5500 data, you must obtain the EIN from the plan sponsor directly.
8
9
18
•
•
If an issuer provides stop-loss and also provides TPA/ASO services to a self-funded plan, enter the name
of the issuer in the “Issuer Name” column and in the “TPA Name” column.
Otherwise, leave the “Issuer Name” column blank.
Issuer EIN
Location: P2 Column M | Format: 9 digits
Only required if an issuer or stop-loss carrier is one of the plan’s reporting entities.
Enter the 9-digit EIN of the company you entered in the Issuer Name field. Do not use dashes. (Example:
012345678.) If there is more than one EIN, enter both EINs in the same cell separated by a semicolon. If the plan
is not insured, leave the cell blank.
TPA Name
Location: P2 Column N | Max Length: 2,048 characters
Only required if TPA or ASO provider is one of the plan’s reporting entities.
Enter the name of the TPA and/or ASO. Do not use slashes. If there is more than one TPA or ASO, separate their
names with a semicolon. If a plan doesn’t have a TPA or an ASO provider, leave the cell blank.
If you are a third-party vendor that does not otherwise act as a TPA and your only relationship with a plan is to
submit data on their behalf, you may (but are not required to) include your company name in the TPA Name
field. (If the plan also has a TPA, separate your company name from the TPA name using a semicolon.)
If you are reporting for a self-administered self-funded plan that doesn’t have a TPA or ASO, you may enter your
company name or you may leave this field blank.
TPA EIN
Location: P2 Column O | Format: 9 digits
Only required if TPA or ASO provider is one of the plan’s reporting entities.
Enter the 9-digit EIN of the company you entered in the TPA Name field. Do not use dashes. (Example:
012345678.) If there is more than one EIN, separate the EINs with a semicolon. If a plan does not have a TPA,
leave the cell blank.
PBM Name
Location: P2 Column P | Max Length: 2,048 characters
Only required if a PBM is one of the plan’s reporting entities.
Enter the PBM name. Do not use slashes. If there is more than one PBM, separate the names with a semicolon.
If a plan doesn’t have a PBM, leave the cell blank.
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.
PBM EIN
Location: P2 Column Q | Format: 9 digits
Only required if a PBM is one of the plan’s reporting entities.
19
Enter the PBM 9-digit EIN without dashes. (Example: 012345678.) If there is more than one PBM, separate the
EINs with a semicolon. If a plan doesn’t have a PBM, leave the cell blank.
Included in D1 – D8
Location: P2 Columns R – Y | 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 0 if the plan’s data is not
included in the respective data file in your submission. For example, if an issuer is submitting only 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.
Example 1: A self-funded group health plan is submitting D1 on its own behalf, a TPA is submitting D2 for that
plan, and a PBM is submitting D3 – D8 for that plan.
P2 submitted by the group health plan
Group
Health
Plan
Name
Plan A
…
Included in
D1
Premium
and Life
Years?
Included in
D2
Spending
by
Category?
Included
in D4 Top
50 Most
Costly
Drugs?
Included in
D5 Top 50
Drugs by
Spending
Increase?
…
Included
in D3 Top
50 Most
Frequent
Brand
Drugs?
1
0
0
0
0
Included
in D6 Rx
Totals?
0
Included
in D8 Rx
Rebates
for the
Top 25
Drugs?
Included in D7
Rx Rebates by
Therapeutic
Class?
0
0
P2 submitted by the TPA (The TPA’s P2 plan list would also have rows for the other plans the TPA is submitting
on behalf of.)
Group
Health
Plan
Name
Plan A
…
Included in
D1
Premium
and Life
Years?
Included in
D2
Spending
by
Category?
Included
in D4 Top
50 Most
Costly
Drugs?
Included in
D5 Top 50
Drugs by
Spending
Increase?
…
Included
in D3 Top
50 Most
Frequent
Brand
Drugs?
0
1
0
0
0
Included
in D6 Rx
Totals?
0
Included
in D8 Rx
Rebates
for the
Top 25
Drugs?
Included in D7
Rx Rebates by
Therapeutic
Class?
0
0
P2 submitted by the PBM
(The PBM’s P2 plan list would also have rows for the other plans the PBM is submitting on behalf of.)
Group
Health
Plan
Name
Plan A
…
Included in
D1
Premium
and Life
Years?
Included in
D2
Spending
by
Category?
Included
in D3 Top
50 Most
Frequent
Brand
Drugs?
Included
in D4 Top
50 Most
Costly
Drugs?
Included in
D5 Top 50
Drugs by
Spending
Increase?
…
0
0
1
1
1
Included
in D6 Rx
Totals?
1
Included in D7
Rx Rebates by
Therapeutic
Class?
1
Included
in D8 Rx
Rebates
for the
Top 25
Drugs?
1
Example 2: A TPA is submitting D2 for Plan A and D1 and D2 for Plan B. The “included in” columns for that TPA’s
P2 file would look like this:
Group
Health
Plan
Name
Plan A
Plan B
…
…
…
Included in
D1
Premium
and Life
Years?
Included in
D2
Spending
by
Category?
Included
in D3 Top
50 Most
Frequent
Brand
Drugs?
Included
in D4 Top
50 Most
Costly
Drugs?
Included in
D5 Top 50
Drugs by
Spending
Increase?
0
1
1
1
0
0
0
0
0
0
Included
in D6 Rx
Totals?
0
0
Included in D7
Rx Rebates by
Therapeutic
Class?
0
0
Included
in D8 Rx
Rebates
for the
Top 25
Drugs?
0
0
20
4.3 P3 FEHB Plan List
FEHB Plan Name
Location: P3 Column A | Max Length: 2,048 characters | Must not be blank
Enter the FEHB Plan Name. Do not use slashes.
FEHB Contract Number
Location: P3 Column B | Max Length: 2,048 characters | Must not be blank
Enter the FEHB Contract Number in this format: XXXX.
FEHB Plan Code
Location: P3 Column C | Max Length: 2,048 characters | Must not be blank
Enter the three-digit FEHB plan code as it appears in the FEHB plan brochure. If there are multiple plan codes,
separate them with a semicolon. (Example: S11; S12.)
States in which the plan is offered
Location: P3 Column D | Max length: 200 characters
Enter the states and territories in which the plan or coverage is offered using two-character state postal code. If
there is more than one state or territory, separate them with a semicolon. (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 two-character postal code for the territories, separated by a semicolon. (Example:
National; PR; GU.)
For purposes of RxDC reporting, a plan is considered “offered” in a state if a person living or working in that
state would be eligible to have coverage under the plan.
Note 1: “States in which the plan is offered” in the plan lists (P2, P3) is not the same thing as “Aggregation State”
in the aggregate data files (D1 – D8). See Section 5.4 for more information on state aggregation.
Note 2: If multiple vendors submit on behalf of the same plan, issuer, or carrier, only one of them is required to
report the states in which the plan is offered.
Plan Year Beginning and End Dates
Location: P3 Columns E and F | Format: MM/DD/YYYY
Enter the plan year beginning and end dates. For FEHB plans, the plan year is the calendar year.
Note: If a plan is included on the plan list solely because it contributed to prior year columns (D5) or restated
rebates (D6, D7, D8) but didn’t contribute to fields for the current reference year, you have the option of
including the plan in the plan list. If you choose to include the prior year plan in the plan list, report 01/01/2023
and 01/02/2023 as the plan year beginning and end dates, respectively, or leave both values blank. (HIOS will
reject submissions if a plan year end date is in the year prior to the reference year.)
Members as of 12/31 of the Reference Year
Location: P3 Column G | Max decimal places: 0
Enter the number of members as of 12/31 of the reference year. Include FEHB covered individuals including
enrollees, annuitants, family members, and Temporary Continuation of Coverage (TCC) enrollees. You must
enter a whole number without decimal places. If a plan year ended before 12/31 of the reference year, enter 0.
Note: In the plan lists, report members as of 12/31 of the reference year. In data file D1, report the average
number of members during the reference year, which is called life-years.
FEHB Carrier Name
Location: P3 Column H | Max Length: 2,048 characters | Must not be blank
21
FEHB Carrier EIN
Location: P3 Column I | Max Length: 2,048 characters | Must not be blank
Enter the 9-digit EIN without dashes. (Example: 012345678.)
Affiliate Name
Location: P3 Column J | Max Length: 2,048 characters
(If different from the FEHB carrier.) If there is more than one value, separate them with a semicolon. If there
isn’t an affiliate, leave this cell blank.
Affiliate EIN
Location: P3 Column K | Max Length: 2,048 characters
(If different from the FEHB carrier.) Enter the 9-digit EIN without dashes. (Example: 012345678.) If there is more
than one value, separate them with a semicolon. If there isn’t an affiliate, leave this cell blank.
TPA or other Third Party Name
Location: P3 Column L | Max Length: 2,048 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 or other Third Party EIN
Location: P3 Column M| Format: 9 digits
Enter the TPA 9-digit EIN without dashes. (Example: 012345678.) If there is more than one TPA, separate them
with a semicolon. Do not use dashes. If a plan doesn’t have a TPA, leave the cell blank.
PBM Name
Location: P3 Column N| Max Length: 2,048 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: P3 Column O | Format: 9 digits
Enter the PBM 9-digit EIN without dashes. (Example: 012345678.) 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: P3 Columns P – W | 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 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.
Example: A reporting entity is submitting D1 – D8 on behalf of Plan A and D1 and D2 on behalf of Plans B and C.
FEHB
Plan
Name
Plan A
Plan B
Plan C
…
…
…
…
Included in
D1
Premium
and Life
Years?
Included in
D2
Spending
by
Category?
Included
in D3 Top
50 Most
Frequent
Brand
Drugs?
Included
in D4 Top
50 Most
Costly
Drugs?
Included in
D5 Top 50
Drugs by
Spending
Increase?
1
1
1
1
1
0
1
0
1
0
1
0
1
0
1
0
1
1
0
0
0
0
0
0
Included
in D6 Rx
Totals?
Included in D7
Rx Rebates by
Therapeutic
Class?
Included
in D8 Rx
Rebates
for the
Top 25
Drugs?
22
5 Data Aggregation
5.1 Overview
In the data files (D1 – D8), aggregate the data for plans that are in the same market segment (Section 5.3) and
the same state (Section 5.4). Within a state and market segment, you should aggregate data for plans that are
associated with the same plan sponsor, issued by the same issuer, administered by the same TPA, or reported by
the same reporting entity (Section 5.5). You cannot aggregate the data to a less granular level than the level
used by the reporting entity that submits the data in file D2 Spending by Category (Section 5.6).
Note: The aggregation state in D1 – D8 is not the same thing as “states in which the plan is offered” in P2 and
P3. See Section 5.4 for more information on determining the aggregation state.
What does it mean to aggregate data?
Aggregating data means that you are combining the information of multiple plans. For example, if a TPA is
submitting D2 for three self-funded small employer plans (Plans A, B, C) and two self-funded large employer
plans (Plan D and E) in Georgia, the TPA should create D2 as follows:
Company
Name
Company
EIN
Aggregation
State
TPA Name
TPA EIN
GA
TPA Name
TPA EIN
GA
TPA Name
TPA EIN
GA
TPA Name
TPA EIN
GA
TPA Name
TPA EIN
GA
TPA Name
TPA EIN
GA
TPA Name
TPA EIN
GA
TPA Name
TPA EIN
GA
TPA Name
TPA EIN
GA
TPA Name
TPA EIN
GA
TPA Name
TPA EIN
GA
TPA Name
TPA EIN
GA
Market
Segment
SF small
employer plans
SF small
employer plans
SF small
employer plans
SF small
employer plans
SF small
employer plans
SF small
employer plans
SF large
employer plans
SF large
employer plans
SF large
employer plans
SF large
employer plans
SF large
employer plans
SF large
employer plans
Spending
Category
Hospital
Primary care
Specialty care
Other medical
costs and services
Known medical
benefit drugs
Estimated
medical benefit
drugs
Hospital
Primary care
Specialty care
Other medical
costs and services
Known medical
benefit drugs
Estimated
medical benefit
drugs
Total
Spending
Total Cost
Sharing
Sum of Plans
A, B, & C
Sum of Plans
A, B, & C
Sum of Plans
A, B, & C
Sum of Plans
A, B, & C
Sum of Plans
A, B, & C
Sum of Plans
A, B, & C
Sum of Plans
A, B, & C
Sum of Plans
A, B, & C
Sum of Plans
A, B, & C
Amounts Not
Applied to
Deductible or
Out-of-Pocket
Maximum
Sum of Plans A,
B, & C
Sum of Plans A,
B, & C
Sum of Plans A,
B, & C
Sum of Plans A,
B, & C
Sum of Plans
D&E
Sum of Plans
D&E
Sum of Plans
D&E
Sum of Plans
D&E
Sum of Plans D
&E
Sum of Plans D
&E
Sum of Plans D
&E
Sum of Plans D
&E
Sum of Plans
A, B, & C
Sum of Plans
D&E
Sum of Plans
D&E
Sum of Plans
D&E
Sum of Plans
D&E
Sum of Plans
D&E
Sum of Plans
D&E
5.2 Column Names
The first four columns of D1 – D8 are the same:
23
Company Name
Location: D1–D8 Column A | Max Length: 256 characters | Must not be blank
This column was formerly named Issuer or TPA Name. The purpose of the column has not changed, only the
name.
Enter the company name that corresponds to the level of aggregation. Do not enter more than one company
name in the same cell. Do not use slashes.
For fully-insured plans, this is usually the name of the issuer. For self-funded plans, this is usually the name of
the TPA. If you are not aggregating at the issuer or TPA level within a state or market, enter the name of the
company that corresponds with the level of aggregation. For example, if you aggregate data at the plan sponsor,
or other reporting entity level, enter the name of the plan sponsor or other reporting entity, respectively.
See Section 5.5 for more information about aggregating data by company.
Company EIN
Location: D1–D8 Column B | Max Length: 9 characters | Must not be blank
This column was formerly named Issuer or TPA EIN. The purpose of the column has not changed, only the name.
Enter the 9-digit EIN of the company that corresponds to the level of aggregation. Do not use dashes. (Example:
012345678.) Do not enter more than one EIN in the same cell.
Note: HIOS has been updated to accept EINs with more than one leading zero.
Aggregation State
Location: D1–D8: Column C | Max length: 100 characters | Must not be blank
This column was formerly named State. The purpose of the column has not changed, only the name.
Enter the state abbreviation that corresponds with the level of aggregation. Do not enter more than one state in
the same cell.
Note: The aggregation state in D1 – D8 is not the same thing as “states in which the plan is offered” in P2 and
P3. For self-funded plans, the aggregation state is generally the state where the plan has its principal place of
business. For fully-insured plans, the aggregation state is generally the state where the policy was issued. See
Section 5.4 for more information on determining the aggregation state.
Market Segment
Location: D1–D8 Column D | Max length: 100 characters | Must not be blank
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 market segment in the same cell.
5.3 Market Segment Aggregation
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.
24
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
Note: The market segments are mutually exclusive. Do not report the same data in more than one market
segment.
To determine the market segment for a group health plan, determine whether the employer is small or large
and whether the plan is fully-insured or self-funded.
Funding Type
A group health plan can be fully-insured, self-funded, or have a combination of funding types. A fully-insured
plan is a plan for which the insurance risk is transferred to an insurance company. With a self-funded plan, the
plan sponsor retains the insurance risk, although the plan may be administered by a TPA. Plan sponsors of selffunded plans sometimes purchase stop-loss insurance or other types of reinsurance to mitigate risk (such as
level-funded plans). For purposes of reporting, plans with stop-loss insurance coverage are still considered selffunded.
For mixed-funded plans, which generally self-fund some benefits and fully insure other benefits, report the selffunded business in the self-funded market segment and the fully-insured business in the fully-insured 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 (MPPs) 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. 10
For level-funded plans, report the business as self-funded. A level-funded plan is a type of self-funded
arrangement in which the plan sponsor makes set monthly payments to a service provider to cover estimated
claims costs, administrative costs, and premiums for stop-loss insurance for claims that surpass a maximum
dollar amount beyond which the plan sponsor is no longer responsible for paying claims (the attachment point).
When claims are lower than expected, surplus payments may be refunded at the end of the contract. These
arrangements are sometimes referred to as balanced funding or alternative funding.
What if a plan sponsor moves from a fully-insured product to self-funded coverage during the reference year
(or vice versa)?
Report the fully-insured business in the small group or large group market segments, as applicable, and the selffunded business in the self-funded small employer or large employer market segments, as applicable.
“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.
10
25
Employer Size
For group health plans, the market segment (small or large) is based on the number of employees. 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 employees employed on business days
during the calendar year preceding the reference year. Include employees that do not have health coverage
when you determine the size of the employer. Do not include dependents or retirees when counting the number
of employees.
How do I count the number of employees?
Use any reasonable method that accounts for full-time, part-time, and seasonal employees. Examples of
reasonable methods include (1) the full-time equivalent employee 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 accounts for non-full-time 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 0.70. 11 For example, if
40 employees are covered by a plan, then the estimated employer size is 57 (40 ÷ 0.70 = 57).
How do I determine employer size if a plan covers more than one employer?
Self-funded multiemployer plans should use the total number of employees employed by the employers that are
contributing to the plan pursuant to a collective bargaining agreement.
A self-funded multiple employer welfare arrangement (MEWA) that is considered an employee welfare benefit
plan established or maintained by an employer as defined under section 3(5) of the Employee Retirement
Income Security Act of 1974 (ERISA) 12 should determine the total number of employees (as defined under ERISA
section 3(6)) of the bona fide employer group or association that constitutes the employer under ERISA section
3(5).
The divisor is based on estimated take-up rates from the 2023 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 take-up rate for healthcare benefits for employers with fewer than 100 employees.
https://www.bls.gov/ebs/publications/employee-benefits-in-the-united-states-march-2023.htm
12
See section 3(40) of the Employee Retirement Income Security Act of 1974 (ERISA); see also, e.g., Department of Labor
Advisory Opinion 2008–07A, available at https://www.dol.gov/sites/dolgov/files/EBSA/about-ebsa/our-activities/resourcecenter/advisory-opinions/2008-07a.pdf; U.S. Department of Labor, Multiple Employer Welfare Arrangements under the
Employee Retirement Income Security Act (ERISA): A Guide to Federal and State Regulation (2022), available at
https://www.dol.gov/sites/dolgov/files/ebsa/about-ebsa/our-activities/resource-center/publications/mewa-under-erisa-aguide-to-federal-and-state-regulation.pdf.
11
26
A self-funded MEWA that is not considered to be an employee welfare benefit plan should determine the
number of employees (as defined under ERISA section (3)(6)) of each underlying employer and report data
according to whether the employer is a small employer or large employer.
5.4 State Aggregation
Note: In the data files (D1 – D8), report a plan’s business in only one state even if the plan is offered
in multiple states.
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 selffunded 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 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.
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 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.
How do I determine the principal place of business?
You may use any reasonable method to determine the principal place of business for purposes of these
prescription drug reporting requirements. For example, you could use the state where the plan is administered,
the state whose laws govern the plan, or the state where most employees reside, work, or receive care.
Note: The principal place of business for purposes of state aggregation must be in the U.S.
5.5 Company Aggregation
In the data files, you have several choices on how to aggregate data to the company level. Within a state and
market segment, you may aggregate data using the following approaches (if they are not precluded by the
Aggregation Restriction in Section 5.6):
•
•
•
•
•
All coverage associated with the same plan sponsor
All coverage issued by the same issuer
All coverage administered by the same TPA
All coverage reported by the same reporting entity
All coverage offered by the same FEHB carrier 13
13
If a carrier is affiliated or associated with an issuer, TPA, or other third-party such as a vendor or underwriter, we
generally expect that the issuer, TPA, or other third-party will include the carrier’s business in the FEHB market segment of
27
Generally, we expect reporting entities to aggregate at the issuer or TPA level. If you are not aggregating to the
issuer or TPA level, enter the name and EIN of the company associated with the aggregation level. For example,
if you are aggregating to the plan sponsor level, enter the name and EIN of the plan sponsor.
It’s acceptable to aggregate to different levels on different data files, as noted in Section 5.6. It is also acceptable
to aggregate to different levels within the same data file. For example, if you are reporting for multiple selffunded plans, you may aggregate and report at the plan sponsor level for some plans and aggregate and report
for the other plans at the TPA level within the same data file.
If a parent company has subsidiaries with separate EINs, may I report according to the parent company EIN?
If the same coverage is offered for all subsidiary companies, you may report according to the parent company
EIN.
Dual-contract health insurance coverage
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.
5.6 Aggregation Restriction
Note: Starting with the RxDC report for the 2023 reference year, the aggregation restriction will no longer be
suspended. Enforcement of the aggregation restriction will facilitate data analysis for the purposes of
developing the biannual public report required under section 9825(b) of the Code, section 725(b) of ERISA, and
section 2799A–10(b) of the PHS Act.
What is the aggregation restriction?
Under 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:
•
•
If the data submitted in D2 is aggregated according to the plan sponsor EIN, the data in D1, D3, D4, D5,
D6, D7, and D8 must also be aggregated according to the plan sponsor EIN.
If the data submitted in D2 is aggregated according to the Issuer or TPA EIN (or some other level that is
not the plan sponsor level), then the reporting entities for D1, D3, D4, D5, D6, D7, and D8 may choose to
aggregate at the same level used in D2 or to aggregate according to the plan sponsor EIN. The reporting
entities for D1, D3, D4, D5, D6, D7, and D8 do not have to make the same decision. For example, if D2 is
at the TPA level, the reporting entity for D1 could aggregate at the plan sponsor level and the reporting
entity for D4 could aggregate at the TPA level.
its submission, rather than the carrier creating a separate submission. If a carrier chooses to make its own submission, it
needs to make sure that the issuer, TPA, or other third party does not report the same data.
28
When more than one reporting entity is submitting D2 on behalf of the same plan, issuer, or carrier, the
reporting entity that submitted D2 at the most granular level shall serve as the aggregation level to use for the
purposes of the aggregation restriction.
5.7 Examples of Aggregate Reporting
Below are examples of aggregated data files. Not all columns are shown.
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.
Company EIN
Aggregation
Market Segment
Total Spending
Total Cost Sharing
State
EIN for Issuer A
CA
Individual market
$177,141,997
$21,733,552
EIN for Issuer A
CA
Small group market
$8,419,411
$1,099,238
EIN for Issuer A
CA
Large group market
$23,735,387
$3,061,628
EIN for Issuer A
WA
Individual market
$168,409
$22,107
EIN for Issuer A
WA
Student market
$377,582
$55,690
Example 2: Issuer reports for multiple issuers that are subsidiaries of 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.
Company EIN
Aggregation
Market Segment
Total Spending
Total Cost Sharing
State
EIN for Issuer X
CO
Individual market
$10,437
$1,404
EIN for Issuer X
CO
Small group market
$333,803,307
$39,962,932
EIN for Issuer X
CO
Large group market
$107,047,027
$15,617,091
EIN for Issuer X
ID
Large group market
$219,568
$26,072
EIN for Issuer X
WY
Large group market
$73,114
$9,362
EIN for Issuer Y
PA
Small group market
$7,234,076
$1,002,860
EIN for Issuer Y
PA
Large group market
$231,331,535
$27,706,578
EIN for Issuer Y
NY
Small group market
$7,234,076
$1,009,009
EIN for Issuer Y
NJ
Small group market
$23,375,484
$2,696,362
EIN for Issuer Z
NJ
Small group market
$1,781,722
$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.
Company EIN
Aggregation
Market Segment
Total Spending
Total Cost Sharing
State
EIN for Issuer B
CO
Individual market
$58,971,803
$9,304,571
EIN for Issuer B
CO
Small group market
$338,403
$35,147
EIN for Issuer B
CO
FEHB plans
$728,966,601
$88,562,152
EIN for Issuer B
CO
SF large employer plans
$219,568
$30,149
EIN for Issuer B
ID
Individual market
$150,268
$23,162
EIN for Issuer B
ID
Small group market
$25,441,865
$3,912,450
29
Company EIN
EIN for Issuer B
EIN for Issuer B
Aggregation
State
ID
WY
Market Segment
Large group markets
SF large employer plans
Total Spending
$1,295,869
$170,953,419
Total Cost Sharing
$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.
Company EIN
Aggregation
Market Segment
Total Spending
Total Cost Sharing
State
EIN for TPA C
KY
SF small employer plans
$162,827,074
$17,407,842
EIN for TPA C
KY
SF large employer plans
$404,143,910
$51,431,354
EIN for TPA C
LA
SF small employer plans
$370,421
$49,929
EIN for TPA C
MI
SF small employer plans
$455,249,960
$70,231,411
EIN for TPA C
MI
SF large employer plans
$1,077,284,699
$142,352,400
EIN for TPA C
MN
SF large employer plans
$2,386,062
$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 selffunded plans administered by TPA F, TPA G, and Issuer D. Issuers D and E and TPA F are aggregating their D2s at
the issuer/TPA level. TPA G is aggregating its D2 at the TPA level for its self-funded small employer plan clients,
and at the plan sponsor level for its only two self-funded large employer plan clients M and N. (See Section 9.2
for information about allocating prescription drug rebates across plans, issuers, carriers, states, and markets.)
Company 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 Plan
Sponsor M
EIN for Plan
Sponsor N
Aggregation
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
Total Rebates, Fees
and Other
Remuneration
$65
$2,278
$669,043
$1,372
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
$435,422
$456
$45,212
$1,445,822
$45,212
$483,284
$897,556
$212,306
CT
SF large employer plans
$341,210
$84,212
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 offers several plans that employees can
choose from. Some plans are fully-insured; some plans are self-funded.
30
Company EIN
Plan Sponsor EIN
Plan Sponsor EIN
Aggregation
State
NV
NV
Market Segment
Large group market
SF large employer plans
Total Spending
Total Cost Sharing
$ 9,619,527
$34,540,901
$1,119,521
$5,485,786
It is also acceptable for the plan sponsor to report using the name and EIN of the issuer and TPA, respectively.
Company EIN
Aggregation
State
NV
NV
Issuer EIN
TPA EIN
Market Segment
Large group market
SF large employer plans
Total Spending
Total Cost Sharing
$ 9,619,527
$34,540,901
$1,119,521
$5,485,786
See Section 6.2 for additional reporting examples when a plan has multiple issuers or multiple TPAs.
6 D1 Premium and Life-Years
Data file D1 collects combined information about a plan’s medical and pharmacy benefits. If a plan has a carveout benefit, you have two options:
• Preferred option: One reporting entity combines information for all benefits and submits one D1 file.
• More than one reporting entity submits D1 on behalf of the plan. When CMS compiles the files, the
combined information should account for all of a plan’s benefits.
The second option is not preferred because life-years cannot be fully reconciled if some members do not have
coverage under all benefits. There is also an increased risk of double-reporting when multiple D1 files are
submitted.
6.1 Definitions
Use the definitions in this section to report medical and pharmacy benefit premium and life-years in D1
Premium and Life-Years. Columns E and F are monthly averages, column G is an average annual amount, and
columns H – K are annual totals.
Average
Monthly
Premium Paid
by Members
Column E
Average
Monthly
Premium Paid
by Employers
Column F
Life Years
Column G
Earned
Premium
Column H
Premium
Equivalents
Column I
Monthly
Average
Monthly
Average
Annual
Average
Annual Total
(fully-insured
plans)
Annual Total
(self-funded
plans)
Admin Fees
Paid
(included in
Premium
Equivalents
field)
Column J
Annual Total
(self-funded
plans)
Stop Loss
Premium Paid
(included in
Premium
Equivalents
field)
Column K
Annual Total
(self-funded
plans)
Average Monthly Premium
Note: Prior to the 2023 reference year, average premium was calculated on a per-member-per-month basis.
Starting with the 2023 reference year, the monthly average is not on a per-member basis. This means you
should divide annual premium amounts by 12 instead of dividing by member-months when calculating the
average monthly premium.
Average monthly premium paid by members
Location: D1 Column E | Max decimals: 8
31
Report the average monthly premium (or premium equivalents) paid by members during the reference year.
Calculate the average monthly premium (or premium equivalent) by taking the total annual premium (or
premium equivalents) paid by members during the reference year and dividing by 12. You should divide by 12
even if the coverage was not in effect for the entire calendar year.
Include:
• Premium or premium equivalents paid by members for medical and pharmacy coverage (See definition
of premium equivalents below.)
• Advance premium tax credits (APTCs) in the individual and fully-insured small group markets
• Member payments for COBRA coverage, including the 2% administrative fee
• Spousal and tobacco surcharges
Exclude: Premium or premium equivalents paid by employers or other plan sponsors on behalf of members.
Average monthly premium paid by employers
Location: D1 Column F | Max decimals: 8
Not applicable in the individual or student markets. For group health plans and FEHB plans, report the average
monthly premium paid by employers or other plan sponsors on behalf of members.
Calculate the average annual premium (or premium equivalent) by taking the total annual premium (or
premium equivalents) paid on behalf of members and dividing by 12. You should divide by 12 even if the
coverage was not in effect for a member or members for the entire reference year.
Include:
• Premium or premium equivalents paid by employers and other plan sponsors on behalf of members
(including dependents) for medical and pharmacy coverage. 14
• Premium or premium equivalents paid by group trust, association, or MEWA plans if separate employers
or other plan sponsors make premium contributions.
Exclude: Premium or premium equivalents paid by members.
Should premium paid for coverage of an owner of an S-Corporation or Partnership be counted as amount paid
by a member or an amount paid by an employer?
If the owner works for the business and pays their premium out of personal funds, report the premium as an
amount paid by a member.
How should I report premium paid for coverage of a sole proprietor or other small business where the
coverage only covers the owner and/or the owner’s spouse?
If only the owner and/or the owner’s spouse are covered by a fully-insured policy, you may treat the policy as an
individual market policy and you do not have to report whether the amount is paid by a member versus paid by
an employer.
What if I don’t know the amount of premium paid by members versus employers?
Section 204 of the CAA, and the Prescription Drug and Health Care Spending interim final rules (86 FR 66662)
require premium information to be reported separately according to amounts paid by members and amounts
paid by employers. Generally, if you are reporting on behalf of a group health plan or FEHB plan, you must
obtain this information from the plan. If the plan does not provide you this information, then the plan must
submit its own P2 and D1 to CMS.
14
For FEHB plans, the amount paid by the employer is the government contribution within the meaning of 5 U.S.C. 8906.
32
If you are unable to obtain all necessary information to calculate average monthly premium paid by members
and average monthly premium paid by employers from a plan, you should:
•
•
Exclude the plan when calculating average monthly premium paid by members and average monthly
premium paid by employers in columns E and F
Include the plan when calculating life years, earned premium, premium equivalents, admin fees, and
stop-loss premium in columns G - K
Life-years
Location: D1 Column G | 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, COBRA
participants, retirees (except for retirees in a retiree-only plan), and FEHB annuitants are all considered
members. To calculate life-years, you must first calculate member months, as noted below.
To calculate member months:
1. Count the number of members covered on a given day of each month of the reference year, and
2. Add the number of members from Step 1 to calculate total member months for the reference year.
To calculate life-years:
1. Divide member months by 12, and
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, 2023
882
February 1, 2023
872
March 1, 2023
884
April 1, 2023
921
May 1, 2023
924
June 1, 2023
923
July 1, 2023
925
August 1, 2023
916
September 1, 2023
907
October 1, 2023
906
November 1, 2023
902
December 1, 2023
869
Total Member Months
10,831
# of Life-Years
902.58333333
(Total member months / 12)
If you are reporting for multiple plans, add the number of life-years for each plan and report the total amount
for all plans.
Earned premium (fully-insured coverage)
Location: D1 Column H | Max decimals: 8
Report total annual earned premium. Earned premium means all money paid by a member, policyholder,
subscriber, and/or plan sponsor as a condition of the member receiving medical or pharmacy coverage. Earned
33
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. Do not include stop-loss premium.
Premium equivalents (total plan cost for self-funded coverage)
Location: D1 Column I | Max decimals: 8
For self-funded plans and other arrangements that do not rely exclusively or primarily on premiums, report the
total annual premium equivalent amounts representing the total cost of providing and maintaining coverage for
all members.
Premium equivalents may be reported on a cash basis or on a retrospective basis.
Include:
• Medical and pharmacy claims costs (you may use either paid claims or incurred claims)
• Administrative costs, including fees that self-funded plans paid to an ASO, TPA, PBM, or other entity
administering a plan
• Stop-loss premiums
• Network access fees, such as preferred provider organization (PPO) fees
• Payments made under capitation contracts with providers for benefits covered under the plan
Subtract:
• Stop-loss reimbursements 15
• Prescription drug rebates that were received and retained 16 by the group health plan during the
reference year, regardless of whether the payment is retrospective or prospective
Exclude:
• Amounts paid by Medicare
• Premium equivalents that will be reported by a different reporting entity (for example, if a
different reporting entity will report premium equivalents for a pharmacy carve-out or stop-loss
purchased from an outside vendor)
• Amounts related to Flexible Spending Arrangements (FSAs), Health Savings Accounts (HSAs),
Medical Savings Accounts (MSAs), and HRAs (such as contributions, reimbursements, or
administrative costs)
• Amounts related to excepted benefits, including Employee Assistance Programs (EAPs)
• Contributions to a trust that are not contributions for claims incurred but not yet reported
• Copays and coinsurance paid by members
To calculate total annual premium equivalents, an employer with a self-funded plan may use, as the total cost of
providing and maintaining coverage, the same types of costs that are taken into account for purposes of
calculating COBRA premiums (minus the 2% administration charge, if applicable). Report total annual costs, not
For the purposes of calculating premium equivalents, it is acceptable to subtract stop-loss reimbursements based on all
amounts received during the reference year or based only on amounts attributable to the claims within the reference year
that gave rise to reimbursements.
16
See Section 9.1 for more information regarding retained rebates.
15
34
the COBRA rate. Report the total dollar amount actually paid for the reference year, rather than the amounts
used to set the COBRA rate.
Should I include premium or premium equivalents for members of an Employee Group Waiver Plan (EGWP)?
You have the option to include premium or premium equivalents for members of an EGWP if the member is
covered by a medical plan that is not a retiree-only plan, though it is not required. 17 Similarly, you may include
premium or premium equivalents paid for additional pharmacy benefits that are not covered by the EGWP.
Premium and premium equivalents for EGWP members should be net of subsidies and reimbursements. Please
make reasonable efforts to ensure that the data reported in D2 – D8 is consistent with how EGWP data is
reported in D1.
Note: If a reporting entity for D3 – D8 is unable or unwilling to exclude EGWP prescription drug plans (EGWPPDPs), then the reporting entity(ies) for D1 and D2 may include information for EGWP-PDP members even if the
members are covered by a retiree-only medical plan.
Admin fees paid
Location: D1 Column J | Max decimals: 8
Report total annual administrative fees (such as claims processing fees) that self-funded plans paid to an ASO,
TPA, PBM, or other entity administering a self-funded plan. This amount should also be included in Premium
Equivalents.
If a group health plan’s staff, rather than a TPA, performs some of these functions, the plan may, but is not
required to, include a pro-rata portion of these costs in premium equivalents.
Exclude (to the extent possible) 18:
• Fees for FSA administration, wellness programs, or financial or clinical analytics
• Fees paid by the TPA to an external party unless they are pass-through payments from the group health
plan
Stop-loss premium paid
Location: D1 Column K | Max decimals: 8
Report the total annual stop-loss premium paid by the plan to the stop-loss insurer. This amount should also be
included in Premium Equivalents. Do not include premium for stop-loss purchased by an issuer.
6.2 D1 Example
If you are reporting at the plan sponsor level for a plan that has more than one issuer or more than one TPA, you
have two reporting options:
1. Aggregate the data for multiple issuers (or multiple TPAs) within a state and market and enter the plan
sponsor name in the Company Name field, or
2. Aggregate the data separately for each issuer or TPA and enter the name of the issuer or TPA in the
Company Name field.
For example, suppose Plan Sponsor A offers a fully-insured plan where Issuer 1 insures a behavioral health
benefit and Issuer 2 insures the other benefits. Suppose Plan Sponsor A also has a self-funded plan where TPA 1
Cf. FAQs about Affordable Care Act Implementation (Part XI), available at
https://www.dol.gov/sites/dolgov/files/ebsa/about-ebsa/our-activities/resource-center/faqs/aca-part-xi.pdf.
18
The Departments recognize that some reporting entities rely on financial coding systems with limitations with respect to
identifying each fee on the exclusion list.
17
35
administers the medical benefit, TPA 2 administers the pharmacy benefit, and Plan Sponsor A purchases stoploss coverage from Issuer 1.
Note 1: You may leave cells blank in columns E-K if a different entity will report the data. However, all reporting
entities must enter values for columns A – D.
Note 2: Stop-loss premium should be reported in the self-funded market segment.
Option 1: Plan Sponsor Level (not all columns shown)
Comp
Name
(Col A)
Plan
Sponsor
A
Plan
Sponsor
A
Agg
State
(Col C)
GA
GA
Avg Monthly Prm
Paid by Mmbrs
(Col E)
Life-Years
(Col G)
Earned
Prm
(Col H)
Large
group
market
Add annual amts
from Issuers 1 & 2
and then divide by
12
Sum of
prm paid
to Issuer 1
& Issuer 2
SF large
employer
plans
Add annual amts
from TPAs 1 & 2
(including mmbr
portion of TPA
fees & stop-loss)
and then divide by
12
Combined life-yrs
from Issuers 1 &
2. (Don’t doublecount members
covered by both
benefits.)
Mkt Sgmt
(Col D)
Combined life-yrs
from TPAs 1 & 2.
(Don’t doublecount members
covered by both
benefits.)
Prm Equiv
(Col I)
Admin Fees
(Col J)
Stop-loss
Prm
(Col K)
Total plan
costs
including
Admin fees
& stop-loss.
Sum of fees
paid to
TPAs 1 & 2
Stop-loss
prm paid to
Issuer 1
Prm Equiv
(Col I)
Admin Fees
(Col J)
Stop-loss
Prm (Col K)
Total plan costs
including TPA
fees for the
medical benefit
Total plan costs
including TPA
fees for the
pharmacy
benefit
Stop-loss prm
paid to Issuer 1
Total fees
paid to TPA
1
Reporting Option 2: Issuer and TPA Level (Not all columns shown.)
Comp
Name
(Col A)
Agg
State
(Col C)
Issuer 1
GA
Issuer 2
GA
Mkt Sgmt
(Col D)
Large
group
market
Large
group
market
Avg Monthly Prm
Paid by Mmbrs
(Col E)
Avg for Issuer 1
Avg for Issuer 2
Life-years*
(Col G)
Life-yrs
covered by
Issuer 1
Life-yrs
covered by
Issuer 2
GA
SF large
employer
plans
Avg under TPA 1
(including mmbr
portion of TPA
fees)
TPA 2
GA
SF large
employer
plans
Avg under TPA 2
(including mmbr
portion of TPA
fees)
Life-yrs
under TPA 2
Issuer 1
GA
SF large
employer
plans
Avg mmbr portion
of stop-loss
Life-yrs
covered by
stop-loss
TPA 1
Life-yrs
under TPA 1
Earned
Prm
(Col H)
Prm paid
to Issuer 1
Prm paid
to Issuer 2
Total fees
paid to TPA
2
Stop-loss
prm paid to
Issuer 1
*When reporting entities use Option 2, CMS will not be able to calculate total life-years without double-counting members
covered by more than one benefit.
7 D2 Spending by Category
Data file D2 collects information related to a plan’s medical benefit(s). Do not include information related to a
plan’s pharmacy benefit(s).
36
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 example, for the 2023 reference year, include claims incurred during
01/01/2023 – 12/31/2023 and paid or received through March 31, 2024.
For non-calendar plan years, include only the portion of experience that was incurred during the reference year
and paid or received through March 31 of the following calendar year.
7.1 Definitions
Total spending
Location: D2 Column F | 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. This includes fee-for-service and
capitated payments. Report claims on a direct basis (that is, before reinsurance or stop-loss reimbursements,
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 (not applicable for
self-funded plans)
Prescription drug rebates, fees,
and other remuneration, to the
extent known and only if they
are related to coverage under
the plan’s medical benefit
Prescription drug rebates, fees,
and other remuneration that
are expected but have not yet
been received, to the extent
known and only if they are
related to coverage under the
medical benefit
Manufacturer cost-sharing
assistance, to the extent known
and only if it is related to
coverage under the plan’s
medical benefit
•
•
•
•
•
•
•
Exclude
Ineligible claims, such as duplicate
claims, recovered claims
overpayments, and any other
claims that are denied under the
policy’s or plan’s terms
Payments by Medicare
Third-party liabilities paid by other
entities, such as coordination of
benefits claims
Payments for services other than
medical care, such as 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
Contributions to a trust that are
not contributions for claims
incurred but not yet reported
Charges or payments from state
or federal risk adjustment
programs
Total cost sharing
Location: D2 Column G| Max decimals: 8
Include cost sharing when you report Total Spending, and also as a separate data element.
37
Include in Total Cost Sharing
• Deductibles, coinsurance,
and copays, including
amounts that may have
been paid through an FSA,
HSA, MSA, or HRA, and
regardless of whether the
amount was applied to
the deductible or out-ofpocket maximum
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
accounted for as reduced cost
sharing amounts paid by
members, and only if they are
related to coverage under the
medical benefit
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)
• Premium
• Manufacturer cost-sharing
assistance
Amounts not applied to deductible or out-of-pocket maximum
Location: D2 Column H | 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 in Amounts not applied to deductible or out-ofpocket max
• The difference between the billed amount and the
allowed amount for claims from out-of-network
providers (balance billing)
• Denied claims for services within a covered benefit
category, such as:
o Physical therapy service denied because the
member has exceeded the plan’s or policy’s
quantitative limit for physical therapy services
o Comprehensive vision exam denied because
the member has exceeded the maximum
annual benefit for vision services
o Ceramic inlay denied because the procedure
code is not covered under the plan’s or
policy’s dental benefit
• An otherwise covered service denied because it did
not meet the plan’s or policy’s criteria for medical
necessity
• Manufacturer cost-sharing assistance for drugs
covered under the medical benefit that is not counted
toward a member’s deductible or out-of-pocket
maximum as part of an accumulator adjustment
program. 19
Exclude
•
•
•
•
Denied claims for services that are not
within a covered benefit category (such as a
denied dental claim when a plan does not
cover dental services)
Denied claims due to a provider error, such
as double-billing, submitting the wrong
insurance form, or using an incorrect
procedure code
Claims initially denied and subsequently paid
on appeal during the same reference year or
the three months following the reference
year (in this circumstance, report the paid
amount in total spending).
PPO discounts
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.
19
38
7.2 Spending Categories
Location: D2 Column E | 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
Hospital
Primary care
Primary care
Specialty care
Specialty care
Other medical costs and services
Other medical costs and services
Medical benefit drugs: known amounts that were reported
Known medical benefit drugs
in hospital, primary care, specialty care, or other medical
costs and services categories
Medical benefit drugs: estimated amounts that were
Estimated medical benefit drugs
reported in hospital, primary care, specialty care, or other
medical costs and services categories
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.
Hospital
Location: D2 | Max decimals: 8
Report spending on services provided by hospitals to members and billed by the facility.
39
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
o Revenue codes 0115, 0125, 0135, 0145, 0155, 0235, and
0650 – 0659 (hospice)
o Revenue codes 0560 – 0609 (home health)
o Revenue codes 0540 – 0549 (ambulance)
o Revenue code 0981 (Emergency Department)
• 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, covered under a medical benefit.
These include but 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 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
• On-site administration of medications as part of a clinical health
care service.
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)
40
Primary Care Taxonomy Codes
Taxonomy
Taxonomy
Code
Provider Type
Taxonomy Classification
Taxonomy Specialty
163WC1500X
NURSING SERVICE PROVIDERS
REGISTERED NURSE
COMMUNITY HEALTH
163WG0000X
NURSING SERVICE PROVIDERS
REGISTERED NURSE
GENERAL PRACTICE
207QA0505X
ALLOPATHIC & OSTEOPATHIC PHYSICIANS
FAMILY PRACTICE
ADULT MEDICINE
207RG0300X
ALLOPATHIC & OSTEOPATHIC PHYSICIANS
INTERNAL MEDICINE
GERIATRIC MEDICINE
207QA0000X
ALLOPATHIC & OSTEOPATHIC PHYSICIANS
FAMILY PRACTICE
ADOLESCENT MEDICINE
207QG0300X
ALLOPATHIC & OSTEOPATHIC PHYSICIANS
FAMILY MEDICINE
GERIATRIC MEDICINE
207R00000X
ALLOPATHIC & OSTEOPATHIC PHYSICIANS
INTERNAL MEDICINE
NOT APPLICABLE
207RA0000X
ALLOPATHIC & OSTEOPATHIC PHYSICIANS
INTERNAL MEDICINE
ADOLESCENT MEDICINE
208000000X
ALLOPATHIC & OSTEOPATHIC PHYSICIANS
PEDIATRICS
NOT APPLICABLE
2080A0000X
ALLOPATHIC & OSTEOPATHIC PHYSICIANS
PEDIATRICS
ADOLESCENT MEDICINE
208D00000X
ALLOPATHIC & OSTEOPATHIC PHYSICIANS
GENERAL PRACTICE
NOT APPLICABLE
2083P0901X
ALLOPATHIC & OSTEOPATHIC PHYSICIANS
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
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
207Q00000X
PHYSICIAN ASSISTANTS AND ADVANCED
PRACTICE NURSING
PHYSICIAN ASSISTANTS AND ADVANCED
PRACTICE NURSING
ALLOPATHIC & OSTEOPATHIC PHYSICIANS
FAMILY MEDICINE
NOT APPLICABLE
364SA2200X
NURSING SERVICE PROVIDERS
CLINICAL NURSE SPECIALIST
ADULT HEALTH
364SC1501X
NURSING SERVICE PROVIDERS
CLINICAL NURSE SPECIALIST
COMMUNITY HEALTH
364SF0001X
NURSING SERVICE PROVIDERS
CLINICAL NURSE SPECIALIST
FAMILY HEALTH
364SP0200X
NURSING SERVICE PROVIDERS
CLINICAL NURSE SPECIALIST
PEDIATRICS
363AM0700X
363L00000X
363LA2200X
363LC1500X
363LF0000X
363LG0600X
363LP0200X
261QS1000X
363LP2300X
363LW0102X
Specialty care
Location: D2 | Max decimals: 8
41
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, ophthalmologists, and physical,
occupational, and speech therapists that are not billed as part
of hospital or facility services
• Doctor’s office or outpatient care center services provided by
specialists
• Hospital-based specialist services only if the specialist
independently bills for those services
• On-site administration of medications as part of a clinical
health care service.
•
•
•
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 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 (except for amounts billed by an ophthalmologist,
which should be reported in Specialty Care)
• Durable medical equipment
• Medications covered under a medical benefit and not already reported in the
hospital, primary care, or specialty care spending categories
• Wellness services billed on a claim.
•
•
•
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
Which wellness services should I include in the RxDC report?
For the purposes of the RxDC report, wellness services are defined as activities primarily designed to implement,
promote, and improve health. If a wellness service is billed on a claim, include it in the “Other medical costs and
services” spending category in data file D2 Spending by Category. If a wellness service is not billed on a claim or
is not a covered service under a plan or policy, do not include it anywhere in the RxDC report.
Example of a wellness service billed on a claim
42
A member sees a provider for the placement of a nicotine patch to help with smoking cessation, and the
provider submits a claim for providing this service (for example, using codes CPT 1036f and S4990). Report the
amount in the “Other medical costs and services” spending category in data file D2 Spending by Category.
Example of a wellness service not billed on a claim
A member receives a gift card for completing a smoking cessation program. Do not include this wellness service
from the RxDC report.
Medical benefit drugs: known amounts reported in hospital, primary care, specialty care, and other
medical costs and services
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.
Note: You are not required to complete the Total Cost Sharing or Amounts Not Applied to Deductible and/or
Out-of-Pocket Maximum columns for the medical benefit drug spending categories.
Medical benefit drugs: estimated amounts reported in hospital, primary care, specialty care, and other
medical costs and services
Location: D2 | Max decimals: 8 | Abbreviation: Estimated medical benefit drugs
Report the estimated portion of bundled or alternative payment arrangements (or other non-fee-for-service
amounts) that can be attributed to drugs covered under a medical benefit. The amounts 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. You may use any reasonable method to estimate the amounts.
If you report estimated amounts, describe the estimation method you used in the Narrative Response.
Note: You are not required to complete the Total Cost Sharing or Amounts Not Applied to Deductible and/or
Out-of-Pocket Maximum columns for the medical benefit drug spending categories.
7.3 D2 Example
Example: Individual market data from Issuer A aggregated by spending category for North Dakota and South
Dakota
Company
Name
Company
EIN
Agg
State
Issuer A
123456789
ND
Issuer A
123456789
ND
Issuer A
123456789
ND
Issuer A
123456789
ND
Issuer A
123456789
ND
Issuer A
123456789
ND
Market
Segment
Individual
market
Individual
market
Individual
market
Individual
market
Individual
market
Individual
market
Spending Category
Hospital
Total
Spending
Total Cost
Sharing
Amounts Not
Applied to
Deductible or
Out-of-Pocket
Maximum
3580521.90
401066.37
2996850.61
Primary Care
602438.96
75794.03
500619.57
Specialty Care
1418977.71
193444.03
1060628.03
751875.43
186265.76
474019.32
Other medical costs
and services
Known medical
benefit drugs
Estimated medical
benefit drugs
478610.92
14556.00
43
Company
Name
Company
EIN
Agg
State
Issuer A
123456789
SD
Issuer A
123456789
SD
Issuer A
123456789
SD
Issuer A
123456789
SD
Issuer A
123456789
SD
Issuer A
123456789
SD
Market
Segment
Individual
market
Individual
market
Individual
market
Individual
market
Individual
market
Individual
market
Spending Category
Hospital
Total
Spending
Total Cost
Sharing
Amounts Not
Applied to
Deductible or
Out-of-Pocket
Maximum
4570611.94
378986.37
4111798.51
Primary Care
409930.85
94257.97
301538.7
Specialty Care
1073888.69
218862.36
716278.03
563733.18
116404.78
407365.13
Other medical costs
and services
Known medical
benefit drugs
Estimated medical
benefit drugs
549538.92
322523.12
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. Include information for pharmaceutical supplies, medical devices, nutritional
supplements, and OTCs in the appropriate spending category in D2 if the products are covered under a plan’s
medical benefit.
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. Include compounded drugs covered under a pharmacy benefit in D6 but not in D3, D4, D5, D7, or
D8.
Include spending on pharmaceutical supplies, medical devices, nutritional supplements, and OTCs in D6 if
covered by a pharmacy benefit. Do not include spending on pharmaceutical supplies, medical devices,
nutritional supplements, and OTCs in D3, D4, D5, D7, or D8 unless the National Drug Code 20 (NDC) for the
product is in the CMS Drug and Therapeutic Class Crosswalk (“CMS crosswalk”) at
https://www.cms.gov/CCIIO/Programs-and-Initiatives/Other-Insurance-Protections/Prescription-Drug-DataCollection.
Should I include information about prescriptions filled outside of the U.S.?
Plans, issuers, and carriers should make their own determination on whether to include information about
prescriptions filled in other countries.
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.
20
44
Prescription drug definition
For the purposes of RxDC reporting, a prescription drug is defined as a set of NDCs that are grouped together by
name and ingredient. This means that NDCs with the same ingredient are grouped together even if they have
different strengths, dosage forms (example: capsule, tablet, liquid), routes of delivery (example: oral,
intravenous, inhaled), 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 and 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: 2,048 | Drug Code Max Length: 100
The RxDC drug name for brand prescription drugs is the combination of the ingredient name and the brand
name. 21 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. 22 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/Other-InsuranceProtections/Prescription-Drug-Data-Collection.
Example: Crosswalk from NDC to RxDC drug name and code (excerpt for mesalamine)
11-Digit NDC
Labeler
00093922489
54092010001
Teva
Pharmaceuticals
Takeda
59762011701
Greenstone LLC
Generic°
59762011803
Greenstone LLC
Generic
60687055632
American Health
Packaging
ANI
Pharmaceuticals
Generic
62559042007
Brand
Indicator
Generic°
Generic°
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
400 mg/1, 20 blister pack in 1
box, unit-dose
4 g/60mL, 7 bottles in 1 box
RxDC
Drug Name
mesalamine
RxDC
Drug Code
R00525820101000
mesalamine
R00525820101000
mesalamine
R00525820101000
mesalamine
R00525820101000
mesalamine
R00525820101000
mesalamine
R00525820101000
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.
22
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.
21
45
11-Digit NDC
Labeler
69238127403
00023590118
Amneal
Pharmaceuticals
Amring
Pharmaceuticals
Cadila
Healthcare
Cadila
Healthcare
Aphena Pharma
Solutions
Salix
Pharmaceuticals
Allergan, Inc.
58914050101
Allergan, Inc.
Brand
00023585318
Allergan, Inc.
Brand
50090300200
Brand
54092047601
A-S Medication
Solutions
Takeda
54092018981
Takeda
Brand
69918056030
70771111002
70771135302
43353088479
65649010301
Brand
Indicator
Generic
Generic
Generic
Generic^
Brand
Brand
Brand
Brand
00037002207
Meda
Brand
Pharmaceuticals
00037006603 Meda
Brand
Pharmaceuticals
° Authorized generic; ^ Branded generic
Strength, Dosage Form, and
Package
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
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
RxDC
Drug Name
mesalamine
RxDC
Drug Code
R00525820101000
mesalamine
R00525820101000
mesalamine
R00525820101000
mesalamine
R00525820101000
mesalamine
[Apriso]
mesalamine
[Apriso]
mesalamine
[Asacol]
mesalamine
[Canasa]
mesalamine
[Delzicol]
mesalamine
[Delzicol]
mesalamine
[Lialda]
mesalamine
[Pentasa]
mesalamine
[Rowasa]
mesalamine
[Rowasa]
R00525820101001
Example: Data aggregated by RxDC drug name (not all columns shown)
Company
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
R00525820101001
R00525820101002
R00525820101003
R00525820101004
R00525820101004
R00525820101005
R00525820101006
R00525820101007
R00525820101007
Number of paid
claims
9,744
3,904
5,642
2,145
6,015
8,983
198
1,703
Note: To reduce file size, you may leave RxDC Drug Name blank, as long as RxDC Drug Code is populated.
Therapeutic classes
Location: D7 | Must not be blank
Therapeutic Class Max Length: 2,048 characters | 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,
46
Aminosalicylate. 23 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. (Example: 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/Other-InsuranceProtections/Prescription-Drug-Data-Collection.
Example: Data aggregated by therapeutic class (not all columns shown)
Company
EIN
123456789
123456789
123456789
123456789
123456789
123456789
Agg
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
Note: To reduce file size, you may leave RxDC Therapeutic Class blank, as long as RxDC Class Code is populated.
CMS Crosswalk
The CMS Drug and Therapeutic Class Crosswalk (“CMS crosswalk”) contains the RxDC drug code and therapeutic
class code for each NDC. The CMS crosswalk file is available 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
(and the missing NDC is not for a pharmaceutical supply, medical device, nutritional supplement, or OTC drug),
you should assign an RxDC drug name using the naming method described earlier in this Section 8.1. If the
ingredient or ingredient/brand name combination is already in the RxDC crosswalk, use the existing RxDC drug
name and drug code. If the ingredient or ingredient/brand name combination is not in the CMS crosswalk (and
the missing NDC is not for a pharmaceutical supply, medical device, nutritional supplement, or OTC drug), create
a unique RxDC drug code using a method of your choosing. Assign the drug to the most appropriate RxDC
therapeutic class based on existing RxDC therapeutic class names and codes.
If you include data in D3, D4, D5, D7, or D8 for NDCs that are not in the CMS crosswalk, upload a supplemental
document in HIOS to identify the RxDC drug name, RxDC drug code, RxDC therapeutic class name, and RxDC
Code that you used for each NDC. The supplemental file should be a CSV or Excel file.
11-Digit NDC
RxDC Drug Name
RxDC Drug
Code
RxDC Therapeutic
Class
RxDC Class
Code
Note: Do not create additional RxDC drug names for pharmaceutical supplies, medical devices, nutritional
supplements, or OTC drugs.
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-labeling-resources/pharmacologic-class
for more information on EPCs.
23
47
8.2 Rx Utilization
Use the following definitions to report prescription drug utilization.
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 | Max decimals: 0
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.
8.3 Rx Enrollment
Location: D6 Column E| Max decimals: 8
New for 2023: Report the total number of member months covered during the reference year under the
pharmacy benefit for which you are reporting pharmacy spending. Calculate member months as described in the
definition of life-years in Section 6.1. For example, if 100 members were covered for 12 months and another 10
members were covered for only one month, the total number of member months would be 1,210.
If you are reporting information about a carved-out benefit and a different reporting entity (or entities) will
report on the plan’s other benefit(s), include only the members covered by the carved-out benefit for which you
are reporting.
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 and stop-loss reimbursements, unless specifically stated otherwise in these
instructions).
48
•
•
•
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
cost-sharing reduction
arrangement or program (not
applicable to self-funded
coverage)
Prescription drug rebates,
fees, and other remuneration
(In other words, total
spending is net of prescription
drug rebates, fees, and other
remuneration)
Prescription drug rebates,
fees, and other remuneration
that are expected but have
not yet been received
Manufacturer cost-sharing
assistance, to the extent
known
Exclude
•
•
•
•
•
•
•
Ineligible claims, such as duplicate
claims, recovered claims
overpayments, and any other claims
that are denied under the policy’s or
plan’s terms
Payments by Medicare
Third-party liabilities paid by other
entities, such as coordination of
benefits claims
Payments for services other than
medical care (Example: medical
management, quality improvement,
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
Contributions to a trust that are not
contributions for claims incurred but
not yet reported
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 cost-sharing reduction programs, as
applicable, allocated or attributable to prescription drugs, separately for each state and market segment. The
49
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 an
FSA, HSA, MSA, or HRA, and
regardless of whether the
amount was applied to the
deductible or out-of-pocket
maximum
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 accounted for as
reduced cost sharing
amounts paid by members
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)
• 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:
• Denied claims for prescription drugs that are not on a plan or coverage’s formulary (unless the
prescription is subsequently filled with a generic version or alternate brand version of the same drug)
• 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-of-pocket
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.
Note: A PBM or other reporting entity may determine the top 50 or top 25 drugs using the data of all plans in
the same state and market segment even if the PBM is reporting data at the plan sponsor, issuer, or TPA level
within the state and market segment.
D3 Top 50 Most Frequently Dispensed Brand Name Drugs
50
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 segment.
− 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.
3. Create a table with the top 50 drugs and include a row for every aggregation state, market segment, and
aggregation company.
− 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 segment.
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 aggregation state, market segment, and
aggregation company.
− 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 2022, exclude the drug from
D5 in the 2022 RxDC report and in the 2023 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.
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.
51
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 segment.
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.
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.
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.
Create a table with the top 50 drugs and include a row for every aggregation state, market segment, and
aggregation company.
o This means that there will be 50 rows for every state, market segment, and EIN combination.
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.
o
2.
3.
4.
5.
6.
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
• 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.
What if an NDC is mapped to a different RxDC drug code or therapeutic class code than it was in the prior
year?
When CMS updates the crosswalk each year, it’s possible for an NDC to be assigned to a different RxDC drug
code or therapeutic class. If the mapping of an NDC changes from one year to the next, there are two reporting
options:
• Use the prior year crosswalk for the prior year data and the current year crosswalk for the current year
data, or
• Use the current year crosswalk for both years.
52
D8 Top 25 Drugs with the Greatest Amount of Rebates
Use the following steps to create the Top 25 by Rx Rebates table.
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 aggregation state, market segment, and
aggregation company.
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.
What if I’m reporting for multiple clients and receive multiple Top 50 or Top 25 lists instead of claims-level
data?
If your clients provide a Top 50 or Top 25 list without claims-level data for all drugs, do not add the spending and
utilization to re-calculate a new Top 50 or Top 25 based on the lists from multiple clients. For example, if you
receive the top 50 most costly drug list from two plan sponsors, do not add spending on drugs on both lists to
re-calculate a new list of the top 50 most costly drugs, even if the plans are in the same state and market
segment and have the same issuer or TPA. Instead, “stack” the top 50 lists and report the plan sponsor name
and EIN in columns A and B of the data file.
Example of “stacked” Top 50 list
Company
Name
Company
EIN
Plan
Sponsor A
Plan
Sponsor A
Plan
Sponsor A
Plan
Sponsor A
Plan
Sponsor B
Plan
Sponsor B
Plan
Sponsor B
Plan
Sponsor B
EIN of Plan
Sponsor A
EIN of Plan
Sponsor A
EIN of Plan
Sponsor A
EIN of Plan
Sponsor A
EIN of Plan
Sponsor B
EIN of Plan
Sponsor B
EIN of Plan
Sponsor B
EIN of Plan
Sponsor B
Agg
State
OH
OH
OH
OH
NJ
NJ
NJ
NJ
Market Segment
small group
market
small group
market
small group
market
small group
market
sf large
employer plans
sf large
employer plans
sf large
employer plans
sf large
employer plans
Drug Name
Drug Code
Spending
Increase
Rank
levothyroxine
R00105820101000
1
196660.90
semaglutide
[Ozempic]
R19913020101001
2
134362.70
..
…
…
R00374180101000
50
11229.21
R03273610101001
1
603041.60
R20556410101001
2
469190.50
…
…
…
..
mepolizumab
[Nucala]
R17205970101001
50
…
sumatriptan
adalimumab
[Humira]
lanadelumab
[Takhzyro]
…
Total
Spending
6401.44
53
9 Rebates, Fees, and Other Remuneration
9.1 Definitions
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 (to the extent known):
• Manufacturer rebates received by plans, issuers, or carriers and not passed through to any member or
entity, including rebates that are retained and used to reduce future premiums
• Amounts received directly from a manufacturer or indirectly from a PBM, pharmacy, wholesaler, or
other entity
• 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.
Note: If a PBM or other reporting entity is unable to obtain complete information regarding the rebates, fees,
and other remuneration received or retained by a plan, issuer, or carrier, the reporting entity may report only
the rebates, fees, and other remuneration from any sources known to the reporting entity, and may assume
that known amounts received by the plan, issuer, or carrier were retained by the plan, issuer, or carrier.
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
54
•
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
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. That is, the sum of “Rebates retained by PBMs,” “Rebates retained by
plans/issuers/carriers,” “Rebates passed to members at POS,” and “Net transfer of other remuneration from
manufacturers to plans/issuers/carriers/PBMs.”
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 2023 RxDC report, there would be one column for total rebates for 2023 (as of 3/31/2024) and
another column for restated rebates for 2022 (restated as of 3/31/2024).
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 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 column and the restated prior year column. (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:
55
•
•
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.
Bona fide service fees include, but are not limited to, distribution service fees, inventory management fees,
product stocking allowances, and fees associated with administrative services agreements and patient care
programs (such as medication compliance programs and patient education programs).
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.
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 drugs
Yes
Appropriately accounts
dosage units based on total dosage units for each drug as a
for differences in a
percent of total drug spending for all the
specific drug’s
prescription drugs for which the rebate was
utilization across plans
received.
and issuers.
Based on
Allocate rebates received for multiple drugs
Yes
Approximates
total drug
based on total drug spending for each drug as a
differences in
spending
percent of total drug spending for all the
utilization and spending
prescription drugs for which the rebate was
on rebate eligible
received.
drugs.
Based on
Rebates received for a specific drug are
Yes
Appropriately accounts
billed rebate allocated to a plan, issuer, or carrier and 11for differences in a
amounts
digit NDC based on the rebate amounts billed
specific drug’s
to the pharmaceutical manufacturer for the
utilization across plans
specific plan, issuer, or carrier and drug as a
or issuers.
percent of the total rebate amount billed to
the pharmaceutical manufacturer for all the
PBM’s plans or issuers.
56
Method
Based on
plan’s brand
drug
spending
Based on
enrollment
Based on the
number of
paid claims
Description
Rebate amounts received for multiple drugs
are allocated to a plan, issuer, or carrier based
on the total drug spend for drugs under the
plan, issuer, or carrier as a percent of the total
drug spend for brand drugs under all of the
PBM’s plans 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.
Rebates received for multiple drugs are
allocated to a plan, issuer, or carrier for
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?
Yes, but only if
the PBM receives
rebates only for
brand drugs.
Explanation
Accounts for
differences in
utilization and spending
on rebate-eligible drugs
across plans or issuers.
No
Does not sufficiently
approximate
differences in
utilization and spending
on rebate eligible drugs
across plans or issuers.
No
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.
Net payments from federal or state reinsurance or cost-sharing reduction programs
Issuers that paid into or received payments from federal or state reinsurance programs or cost-sharing reduction
programs should describe how they 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, please use the “Upload supplemental document” feature in HIOS to upload an
Excel or CSV table with the RxDC drug name and drug code that you used or created, as well as the therapeutic
57
class name and code, for each missing NDC. that you used (or created for each missing NDC. The supplemental
file should be a table with the following layout:
11-Digit NDC RxDC Drug Name RxDC Drug Code RxDC Therapeutic Class RxDC Class Code
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.
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.
58
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 year beginning date.
Field
P1 Column Name
Instructions
Type
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 4.1.
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 of
Integer The number of enrollees on the last day of the reference
the reference year
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
Integer Valid Values:
and Life Years?
0
(1= Yes; 0 = No)
1
Included in D2 Spending by Integer Valid Values:
Category?
0
(1= Yes; 0 = No)
1
Included in D3 Top 50 Most Integer Valid Values:
Frequent Brand Drugs?
0
(1= Yes; 0 = No)
1
Included in D4 Top 50 Most Integer Valid Values:
Costly Drugs?
0
(1= Yes; 0 = No)
1
Included in D5 Top 50
Integer Valid Values:
Drugs by Spending
0
Increase?
1
(1= Yes; 0 = No)
Integer Valid Values:
Included in D6 Rx Totals?
0
(1= Yes; 0 = No)
1
P1 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
P2 Group Health Plan List
Each row should have a unique combination of Group Health Plan Number, plan year beginning date,
and plan sponsor EIN.
Field
P2 Column Name
Instructions
Type
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.
Carve-out Description
String
Valid values:
• Pharmacy only
• Behavioral health only
• Fertility only
• Specialty drugs only
• Hospital only
• This plan does not include pharmacy benefits
• Medical only
• Other
Leave blank if you are reporting on the majority of the plan’s
benefits as well as a carved-out benefit.
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.
States in which the plan
String
Enter the state(s) in which the plan or coverage is offered
offered
using 2-character state postal code. 24 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 2-character postal
code for the territories, separated by a semicolon. For
example: National; PR; GU.
Market Segment
String
Valid Values:
Small group market
Large group market
SF small employer plans
SF large employer plans
24
In these instructions, the term “State” includes the District of Columbia and the U.S. territories.
60
P2 Column Name
Field
Type
Plan Year Beginning Date
Date
Plan Year End Date
Date
Members as of 12/31 of
the reference year
Integer
Plan Sponsor Name
String
Plan Sponsor EIN
String
Issuer Name
String
Issuer EIN
String
TPA Name
String
TPA EIN
String
PBM Name
String
PBM EIN
String
Included in D1 Premium
and Life Years?
(1= Yes; 0 = No)
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)
Integer
Integer
Integer
Integer
Instructions
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.
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.
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
61
P2 Column Name
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
Instructions
Valid Values:
0
1
Valid Values:
0
1
Valid Values:
0
1
Valid Values:
0
1
P3 FEHB Plan List
Each row should have a unique combination of FEHB contract number, FEHB plan code, and plan year
beginning date.
Field
P3 Column Name
Instructions
Type
FEHB Plan Name
String
FEHB Contract Number
String
Enter the FEHB Contract ID.
FEHB Plan Code
String
Enter the three-digit FEHB plan code as it appears in the
FEHB plan brochure. Separate each three-digit plan code
with a semicolon. Ex: 511; 512.
States in which the plan is
String
Enter the states and territories in which the plan is offered
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 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.
Members as of 12/31 of
Integer
The number of FEHB covered individuals, including
the reference year
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.)
62
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)
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)
Integer
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)
Integer
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. 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
Valid Values:
0
1
Valid Values:
0
1
63
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
Company Name
String
Enter the name of the issuer, TPA, FEHB carrier, plan
sponsor, or reporting entity as applicable. Do not
enter more than one value.
Company 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.
Aggregation 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
Numeric
Paid by Members
Average Monthly Premium
Numeric
Paid by Employers
Life Years
Numeric
Earned Premium
Numeric
For fully-insured plans.
Premium Equivalents
Numeric
For self-funded plans.
Admin fees Paid (included in
Numeric
For self-funded plans.
the Premium Equivalents field)
Stop-loss Premium Paid
Numeric
For self-funded plans.
(included in the Premium
Equivalents field)
D2 Spending by Category
Each row in D2 must have a unique combination of EIN, state, market segment, and spending category.
D2 Column Name
Field Type Instructions
Company Name
String
Enter the name of the issuer, TPA, FEHB carrier, plan
sponsor, or reporting entity as applicable. Do not
enter more than one value.
Company 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.
Aggregation 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
64
D2 Column Name
Field Type
Spending Category
String
Total Spending
Total Cost Sharing
Amounts Not Applied to
Deductible and/or Out-ofPocket Maximum
Numeric
Numeric
Numeric
Instructions
Large group market
SF small employer plans
SF large employer plans
FEHB plans
Do not enter more than one value.
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.
D3 Top 50 Most Frequent Brand Drugs
Each row in D3 must have a unique combination of EIN, state, market segment, and drug code.
Field
D3 Column Name
Instructions
Type
Company Name
String
Enter the name of the issuer, TPA, FEHB carrier, plan
sponsor, or reporting entity as applicable. Do not
enter more than one value.
Company 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.
Aggregation 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
65
D3 Column Name
Number of Members with a Paid
Claim
Number of Dosage Units
Total Spending
Total Cost Sharing
Manufacturer Cost-Sharing
Assistance
Field
Type
Integer
Instructions
Numeric
Numeric
Numeric
Numeric
D4 Top 50 Most Costly Drugs
Each row in D4 must have a unique combination of EIN, state, market segment, and drug code.
Field
D4 Column Name
Instructions
Type
Company Name
String
Enter the name of the issuer, TPA, FEHB carrier, plan
sponsor, or reporting entity as applicable. Do not
enter more than one value.
Company 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.
Aggregation 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
Integer
Claim
Number of Dosage Units
Numeric
Total Spending
Numeric
Total Cost Sharing
Numeric
Manufacturer Cost-Sharing
Numeric
Assistance
D5 Top 50 Drugs by Spending Increase
Each row in D5 must have a unique combination of EIN, state, market segment, and drug code.
66
D5 Column Name
Company Name
Field Type
String
Company EIN
String
Aggregation State
String
Market Segment
String
Drug Name
String
Drug Code
String
Spending Increase Rank
Integer
Number of Paid Claims
Number of Members with a Paid
Claim
Number of Dosage Units
Total Spending
Total Cost Sharing
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 CostSharing Assistance
Dollar Increase in Total Spending
Integer
Integer
Instructions
Enter the name of the issuer, TPA, FEHB carrier,
plan sponsor, or reporting entity as applicable. Do
not enter more than one value.
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.
Enter the 2-character state postal code. Ex: NY. Do
not enter more than one value.
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.
Enter the drug name from the CMS crosswalk file.
Do not enter more than one value.
Enter the drug code from the CMS crosswalk file.
Do not use NDC. Do not enter more than one
value.
Valid Values: 1-50. Do not enter more than one
value.
Numeric
Numeric
Numeric
Numeric
Integer
Integer
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
Company Name
String
Enter the name of the issuer, TPA, FEHB carrier, plan
sponsor, or reporting entity as applicable. Do not
enter more than one value.
67
D6 Column Name
Company EIN
Field Type
String
Aggregation State
String
Market Segment
String
Rx Enrollment
Total Rx Spending under
Pharmacy Benefit
Rx Amounts Not Applied to
Deductible and/or Out-ofPocket Maximum
Bona Fide Service Fees
PBM Spread Amounts
Total Rebates/Fees/Other
Remuneration
Restated Prior Year
Rebates/Fees/Other
Remuneration
Numeric
Numeric
Instructions
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.
Enter the 2-character state postal code. Ex: NY. Do
not enter more than one value.
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.
Numeric
Numeric
Numeric
Numeric
Numeric
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
Company Name
String
Enter the name of the issuer, TPA, FEHB carrier, plan
sponsor, or reporting entity as applicable. Do not
enter more than one value.
Company 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.
Aggregation 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
68
D7 Column Name
Field Type
Therapeutic Class Name
String
Therapeutic Class Code
String
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 and
Other Remuneration from
Pharmacy to
Plan/Issuer/Carrier
Total Rebates/Fees/Other
Remuneration
Restated Prior Year
Rebates/Fees/Other
Remuneration
Integer
Integer
Instructions
Do not enter more than one value.
Enter the therapeutic class name from the CMS
crosswalk file. Do not enter more than one value.
Enter the therapeutic class code from the CMS
crosswalk file. Do not enter more than one value.
Numeric
Numeric
Numeric
Numeric
Numeric
Numeric
Numeric
Numeric
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.
D8 Column Name
Field Type
Instructions
Company Name
String
Enter the name of the issuer, TPA, FEHB carrier,
plan sponsor, or reporting entity as applicable. Do
not enter more than one value.
Company 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.
Aggregation 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
69
D8 Column Name
Field Type
Drug Name
String
Drug Code
String
Rebate Rank
Integer
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
Instructions
Large group market
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
Numeric
Numeric
Numeric
Numeric
Numeric
Numeric
Numeric
Numeric
70
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 is the Data Dictionary and the RxDC templates?
The RxDC data dictionary and templates are on the CMS website at
https://www.cms.gov/CCIIO/Programs-and-Initiatives/Other-Insurance-Protections/PrescriptionDrug-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.
You should remove numeric formatting in Excel before saving your file in CSV format.
Do not use 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.
The maximum file size for each CSV file is 200 megabytes.
PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
OMB control number. The valid OMB control number for this information collection is 0938-1407. The information collection included in this
package reflects the time and effort required by group health plans and health insurance issuers to submit certain information to the
Departments about their plan or coverage as well as the time involved by plans and issuers to report total spending on health care services. The
time required to complete this information collection is estimated to average 208 hours per response, including the time to review instructions,
search existing data resources, gather the data needed, and to review and complete the information collection. All information collected will be
kept private in accordance with regulations at 45 C.F.R. 155.260, Privacy and Security of Personally Identifiable Information. 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,
Mail Stop C4-26-05, Baltimore, Maryland 21244-1850, Attention: Information Collections Clearance Officer.
71
| File Type | application/pdf |
| File Title | 2023 RxDC Instructions |
| Subject | Prescription Drug and Health Care Spending |
| Author | CMS |
| File Modified | 2024-04-30 |
| File Created | 2024-04-15 |