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Spotlight Mandate: Pharmacy benefits and prescription drug costs

Medicine, pharmaceutics, health care and people concept - Young female pharmacist giving medications to smiling senior male customer

This regulation will require reporting of specific prescription drug spending and medical cost data annually to the Departments of Health and Human Services, Labor and Treasury (Departments).

Health plans offering group or individual insurance coverage must annually report plan specific prescription drug spending and medical cost data to the Departments.

These reports must include:

  • Average monthly premium paid by employees versus employers
  • Total health care spending broken down by type (hospital care, primary care and specialty care)
  • Prescription drug spending by enrollees versus employers and insurers
  • 50 most frequently dispensed brand prescription drugs
  • 50 costliest prescription drugs by annual spending
  • 50 prescription drugs with the greatest increase in plan or coverage expenditures from the previous year
  • Prescription drug rebates and fees must be reported with some specificity

Who it applies to: Fully insured group health plans, self-funded group health plans and individual policies—including all grandfathered plans.

Effective date: Information for 2020 and 2021 plans years must be reported by Dec. 27, 2022; information must be reported annually thereafter by June 1.

Action required: Additional rulemaking with further reporting guidance is expected in 2022. BCBSND will monitor any additional guidance and will be gathering and submitting the required information to the federal government on behalf of our clients. We will contact self-funded plans for employer/employee premium information and other plan-specific data if not held by BCBSND. We will not be reporting prescription drug information if a self-funded plan has prescription drug coverage outside of BCBSND. Self-insured plans may choose to create and submit their own reports.