PBM-Drug-Pricing-Review

Qualified Health Plans & Pharmacy Benefit Manager Drug Data, Pricing, and Rebate Review (QHP PBM DPR2)


The Affordable Care Act added section 1150(a)(2) of the Social Security Act, requiring pharmacy benefit managers (PBMs) and qualified health plan (QHP) issuers to report prescription drug benefit information to the Department of Health and Human Services (HHS). 

Section 1150A(a)(2) extends this reporting requirement to PBMs that contract with QHP issuers to manage prescription drug coverage. This requirement applies to PBMs contracting with QHP issuers in all states, regardless of Exchange type. This requirement does not extend to health plans offered by QHP issuers that are not QHPs. This requirement does not apply to standalone dental plans. 

What information do PBMs and QHP issuers submit to CMS?

Section 1150A of the Social Security Act requires PBMs and QHP issuers to submit information about: 

  • The percentage of prescriptions provided through retail pharmacies compared to mail order pharmacies, and the generic dispensing rate. 
  • The aggregate amounts and types of rebates, discounts, or price concessions (excluding bona fide service fees) that a QHP issuer or its contracted PBM negotiates that are attributable to patient utilization under the QHP; the aggregate number of rebates, discounts, or price concessions that are passed through to the QHP issuer; and the total number of prescriptions that were dispensed.  
  • The aggregate difference between the amount the QHP pays the PBM and the amount that the PBM pays retail and mail order pharmacies (commonly referred to as spread pricing).

How does CMS use this information?

Submitted data helps CMS better understand the costs of prescription drugs and the role that PBMs play in the drug industry.  

Is this information publicly available?

Pursuant to the statute, CMS may only share collected information with the Government Accountability office (GAO), Congressional Budget Office (CBO), and the states for the purpose of operating an Exchange. Therefore, CMS cannot make this information publicly available.

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Page Last Modified:
05/31/2024 05:54 PM
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