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 PY2023: 

  • No changes for the 2023 QHP Application.

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 HIOS includes only the Number of Tiers and Drug Tier Type fields for the first formulary associated with each drug list. 
Application Resources