Group Health Plan Reporting Requirements for Pharmacy Benefits due to Consolidated Appropriations Act (CAA) of 2021

Group health plans (self-insured employers)  should be preparing for the new annual reporting requirement related to pharmacy benefits and drug costs because of the CAA, 2021.  

Reports must be submitted no later than one year after the date of enactment date. Subsequent filings must be completed by June of each subsequent year.  

The information reports must include the following: 

  • Beginning and end date of plan years. 
  • Number of enrollees 
  • Each state in which the plan is offered 
  • 50 brand prescription drugs most frequently dispensed and paid for by the plan and the total number of claims for each drug 
  • 50 most costly drugs paid for by the plan based on total annual drug spend and annual amount of spend for each drug 
  • 50 prescription drugs with the greatest increase in spend over the prior year and for each drug the percentage increase  
  • Total spending on healthcare services broken down by the types of costs, including (1) hospital, healthcare provider, and clinical service costs, for primary care and specialty care separately; (2) costs for prescription drugs; and (3) other medical costs, including wellness services. In addition to types of costs, spending on prescription drugs would need to be broken down by the health plan spend and the participants’ and beneficiaries spend 
  • Average monthly premium spent by employers and employees 
  • The impact on premiums by rebates, fees, and any other compensation paid by drug manufacturers to the plan, with respect to prescription drugs prescribed to enrollees in the plan or coverage, including the amounts paid for each therapeutic class of drugs, and the amounts paid for each of the 25 drugs that yielded the highest amount of rebates and other compensation under the plan or coverage from drug manufacturers during the plan year. 
  • Any reduction in premiums and out-of-pocket costs associated with rebates, fees, or other compensation described in the preceding paragraph. 

The CAA requires that the Secretary of HHS make available on the Department of HHS website a report on prescription drug reimbursements under group health plans and group and individual health insurance coverage, prescription drug pricing trends, and the contribution of prescription drug costs to premium increases or decreases under such plans or coverage in aggregate no later than 18 months after the first informational report is submitted. 

Lisa Early is an Account Executive for PBGH

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