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 PY2024:

  • For Standardized Plan Options (SPOs), issuers should have four tiers of prescription drug cost sharing. The cost sharing should conform with the following benefits specified in the Final HHS Notice of Benefit and Payment Parameters for 2024: generic drugs, preferred brand drugs, non-preferred brand drugs, and specialty drugs. If you include the Zero Cost Share Preventive Drugs tier type, that tier type must be entered as Tier 1 for the associated formulary ID within the Prescription Drug Template. If you include the Medical Service Drugs tier type, that tier type must be entered as the highest tier for the associated formulary ID within the Prescription Drug Template. Finally, if you include both the Zero Cost Share Preventive Drugs and the Medical Service Drugs tier types in their standardized plan options, you should enter Zero Cost Preventive Drugs for Tier 1, Generic Drugs for Tier 2, Preferred Brand Drugs for Tier 3, Non-preferred Drugs for Tier 4, Specialty Drugs for Tier 5, and Medical Services Drugs for Tier 6.
  • The template will now allow you to enter a duplicate instance of an RXCUI on the Drug Lists tab. Each RXCUI you choose to duplicate may only be duplicated once in the template. If you offer one drug list, the one instance of the duplicate RXCUI must be assigned to a tier that corresponds to the Zero Cost Share Preventive Drugs tier type on the Formulary Tiers tab. If you offer more than one drug list, you may enter values of “NA” for both instances of the RXCUI, denoting the RXCUI is not covered on that drug list, or you may enter the value of “NA” for one instance of the duplicate RXCUI and may assign the second instance of the duplicate RXCUI to any other tier.
  • SPOs of different metal levels must have distinct formulary IDs selected to ensure the appropriate cost sharing is assigned for that plan’s level of coverage.
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 you offer plans in the Individual and SHOP Markets, you must create separate formulary IDs for each market, regardless of whether the formulary is intended to serve both markets. If you submit via the National Association of Insurance Commissioners’ (NAIC’s) System for Electronic Rates & Forms Filing (SERFF) you must use the same Prescription Drug Template across all binders or ensure that no formulary IDs repeat across the binders.
Application Resources