Prescription Drug Data Collection (RxDC) Reports
What are RxDC Reports?
RxDC reports are federally required annual submissions to the Centers for Medicare & Medicaid Services (CMS). They were introduced under the Consolidated Appropriations Act (CAA) of 2021 and require health plans and insurers to disclose information about:
•Prescription drug costs
•Medical claims spending
•Premiums and employee/employer contributions
•Pharmacy benefit and prescription drug rebates
The goal is to provide transparency on healthcare spending, particularly around prescription drugs.
Who is responsible for filing RxDC reports?
The ultimate responsibility lies with health insurers (for fully insured plans) or plan sponsors/employers (for self-funded group health plans).
•Fully Insured Plans: The carrier (insurer) generally takes responsibility for submission.
•Self-Funded Plans: The plan sponsor (employer) is responsible but may delegate reporting duties to third-party administrators (TPAs) or Pharmacy Benefit Managers (PBMs).
Who is responsible for filing RxDC reports?
The ultimate responsibility lies with health insurers (for fully insured plans) or plan sponsors/employers (for self-funded group health plans).
•Fully Insured Plans: The carrier (insurer) generally takes responsibility for submission.
•Self-Funded Plans: The plan sponsor (employer) is responsible but may delegate reporting duties to third-party administrators (TPAs) or Pharmacy Benefit Managers (PBMs).
What role do TPAs play in RxDC reporting?
Third-Party Administrators (TPAs) are often engaged by self-funded employers to handle claims administration and reporting. In the RxDC context:
•TPAs typically provide medical claims data needed for the report.
•They may prepare and file reports on behalf of employers if contracted to do so.
•TPAs coordinate with PBMs to combine medical and pharmacy data into a compliant report.
However, unless explicitly agreed in writing, TPAs are not automatically responsible for submission—the employer remains accountable.
What role do PBMs play in RxDC reporting?
Pharmacy Benefit Managers (PBMs) are critical because they control prescription drug claims and rebate data. Their responsibilities may include:
•Supplying detailed drug utilization and cost data.
•Reporting rebates, fees, and other remuneration from drug manufacturers.
•Providing files directly to CMS or sending them to the TPA/employer for consolidation.
Just like TPAs, PBMs’ obligations depend on their contract with the plan sponsor—some may provide full submissions, while others only supply data files.
How do TPAs and PBMs work together in the process?
Since RxDC requires both medical and pharmacy data, TPAs and PBMs often need to coordinate:
•TPAs → handle medical claim reporting.
•PBMs → handle prescription drug data and rebates.
•Both may deliver separate files that must be merged for a complete employer submission.
Employers must ensure both vendors are aligned and that all required files are submitted to CMS.
What happens if RxDC reports are not filed?
Non-compliance could expose plan sponsors to:
•CMS enforcement actions
•Penalties for failing to meet federal reporting requirements
•Potential fiduciary concerns under ERISA for self-funded plans
In summary:
•Employers (plan sponsors) are ultimately responsible.
•TPAs provide medical claims data and sometimes file reports.
Self Fund Health's TPA, Yuzu is committed to filing these on behalf of our employer clients currently.
•PBMs provide drug data and rebate information.
•Coordination is essential to ensure a complete and compliant RxDC submission.