Prescription Drug FAQs
Q1: How would an issuer who is already using all of the available seven (7) tier types within the Prescription Drug Template incorporate the drug tier type of Medical Service Drugs?- The Prescription Drug Template cannot fully accommodate a formulary design that includes more than seven (7) formulary tiers. If the plans associated with the formulary cannot meet the essential health benefit (EHB) count unless medical drugs are included in the drug list, the Centers for Medicare & Medicaid Services (CMS) recommends taking the following steps to submit the Qualified Health Plan (QHP) Application:
- Enter all RXCUIs covered under the plan’s prescription drug benefit in the Prescription Drug Template, for each of the issuer’s drug lists.
- Use the Combined Prescription Drug Supporting Documentation and Justification to identify how the drug list meets the requirement and submit the RXCUIs associated with the medical drugs for each drug list.
Q2: Can issuers input drugs covered under the medical benefit on separate formulary tiers in the Prescription Drug Template or should "medical drugs" be included in the justification?
- Issuers should include only drugs covered under the pharmacy benefit on the Drug List worksheet in the Prescription Drug Template. If an issuer offers drugs under the medical benefit and needs those drugs in order to satisfy the state benchmark drug count, the issuer must include the drugs covered under the medical benefit in the Combined Prescription Drug Supporting Documentation and Justification form, and submit the RXCUIs associated with the medical drugs for each drug list. Justification forms are located on the QHP website.