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 PY21:

  • Formulary URLs are no longer collected in the Prescription Drug section. Issuers must now submit their URLs via the Supplemental Submission Module (SSM).

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.
  • All formularies associated with the same drug list should have the same Number of Tiers and the same Drug Tier Type for a given tier. In other words, each drug list may have only one tier structure, as indicated by the number of tiers and drug tier types. The .XML 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