Data File #6 – Complexity in Prescription Drug & Healthcare Cost Reporting

PBMs are telling their clients “we have you taken care of” on the data submissions for this new reporting, but as you dig in you begin to understand that cannot possibly be the case.  We have covered in other blogs the issues regarding the Narrative File, Plan Files and Data Files #1 & #2.  For this post we will focus on a portion of the Data File #6.

For the Rx Totals it is required to submit prescription drugs covered by non-pharmacy benefits.  The instructions go on to say “you must make a good faith effort to obtain the information on these costs to the best of your ability”

Non-pharmacy drug benefits are drugs that a plan participant is prescribed at a location other than a pharmacy, such as in a hospital.  These type of claims are not typically paid by the PBM but rather are charged to a plan by the TPA under the medical benefits.

What are we saying here?  The PBM does not have this data … they must get the data from the TPA.  Again, this isn’t the end of the world but it does require coordination to ensure:

  • You meet your good faith effort requirements
  • Your reporting is accurate &
  • Your reporting is timely