Prescription Drugs

Issuers cannot use or implement any benefit designs that have the effect of discriminating against individuals on the basis of age, expected length of life, present or predicted disability, quality of life, or other health conditions. CMS uses the data collected in this portion of the QHP Application to review compliance for non-discrimination standards.

Key Changes for PY2025:

  • After selecting a formulary ID on the Formulary Tiers tab, the associated Drug List ID field will automatically populate as drug list ID 1.
  • The 1 Month Out of Network Retail Pharmacy Benefit Offered?, 3 Month In Network Mail Order Pharmacy Benefit Offered?, and 3 Month Out of Network Mail Order Pharmacy Benefit Offered? fields will no longer automatically populate as No.
Tips for the Prescription Drug Section
  • RXCUIs should have one of the following term types (TTYs): semantic branded drug (SBD), semantic clinical drug (SCD), brand name pack (BPCK), or generic pack (GPCK).
  • Set Tier Level equal to “NA” (not applicable) if the drug is not part of a given drug list.
  • Each drug list may have only one tier structure, as indicated by number of tiers and drug tier types, and all formularies associated with each drug list must be identical. The .XML file generated from the template and submitted to MPMS includes only the Number of Tiers and Drug Tier Type fields for the first formulary associated with each drug list.
  • If plans are offered in the Individual and Small Business Health Options Program (SHOP) Markets, you must create separate formulary IDs for each market, regardless of whether the formulary is intended to serve both markets. Issuers submitting via the National Association of Insurance Commissioners’ (NAIC’s) System for Electronic Rates & Forms Filing (SERFF) must use the same Prescription Drug Template across all binders or ensure that no formulary IDs repeat across the binders.
Application Resources