Understanding Data and Plan File Submissions for Prescription Drug & Healthcare Reporting

In total a Plan Sponsor must submit (or have submitted on their behalf) 8 different files via the CMS portal.  It is not necessary that the same reporting entity send in all 8 files, however it is mandatory that you NOT submit any duplicate files.

Plan List Files

  • These are 3 different files but you will only submit one of them, depending upon the type of reporting entity you are.  Essentially these are files that provide identifying information that will match up to the data files.

Data Files

  • These are 8 different files that contain different data pieces required to be submitted annually

Narrative File

  • This 1 file is submitted with explanatory information to assist the departments in understanding the methodology used to create the data files.

*Note – remember for fully insured groups the carrier will handle the reporting.  For self-insured, level funded or minimum premium groups this responsibility falls on the Plan Sponsor.

There are many challenges that exist with the submission of these files, including:

  • PBMs have the data necessary for data file #’s:  3, 4, 5, 7 & 8.
  • PBMs will need the assistance of TPAs to complete data file #6
  • TPAs will be mainly the party providing data files #1 & #2, however they will require additional data from plan sponsors
  • Plan files will need coordination between the TPA and Plan Sponsor.
  • The narrative file will require data from the TPA, PBM and Plan Sponsor