How to Complete the Prescription Drug Template
Issuers seeking to offer qualified health plans or QHPs, including
stand-alone dental plans, or SADPs, on the Federally-facilitated Exchange must submit a
completed QHP Application per CMS guidelines. As part of the QHP certification process,
issuers are asked to fill out several templates with issuer- and plan-level data. These templates,
along with any supporting documentation submitted, comprise an issuer’s QHP Application.
Among these templates is the Prescription Drug Template. The Prescription Drug Template
collects formulary information associated with an issuer’s plans. A formulary contains cost sharing
information for drug benefits. The template creates unique formulary IDs that are later mapped
to plans entered in the Plans & Benefits Template. To download the Prescription Drug Template and
applicable instructions, visit the Prescription Drug webpage of the QHP certification website.
This webpage contains more information about the Prescription Drugs section of the QHP Application,
including tips and additional resources. Before filling out the Prescription Drug Template,
download and read the instructions from the Application Resources section.
Additionally, you’ll need a list of valid RXCUIs.
Download the most recent list from the Unified Medical Language System, or UMLS. If you do
not have an account or license with UMLS, refer to the QHP Application Instructions.
Issuers are permitted to offer drugs that do not have associated RXCUIs,
but those drugs should not be included in the Prescription Drug Template and are not used in
evaluating essential health benefit, or EHB, benchmark or non-discrimination compliance.
Once you’re ready to complete the Prescription Drug Template, download
the template from the Application Resources section, open the template, and enable macros.
There are two worksheets within the Prescription Drug Template. The Formulary Tiers worksheet
allows you to define the cost sharing for each formulary and associate each formulary with a drug
list. The Drug Lists worksheet collects specific drug information, including drug tier placements
and utilization management requirements. A drug list can be linked to more than
one formulary, but a formulary cannot be linked to more than one drug list.
Now let’s walk through filling out the Prescription Drug Template with sample data.
Before you begin, look through the data elements required to ensure you
have the necessary formulary information to successfully complete this template.
To begin, in the top left corner of the Formulary Tiers worksheet,
enter the 5-digit HIOS Issuer ID you received when you registered in the Health Insurance
Oversight System, or HIOS, and the state where the applicable plans will be offered. Then navigate
to the Drug Lists worksheet, where you will enter all RXCUIs included in your drug lists.
All RXCUIs should have one of the following term types in the UMLS list: semantic branded drug, or SBD,
semantic clinical drug, or SCD, brand name pack, labeled BPCK, or generic pack, labeled
GPCK. The drug list should include all drugs on your formulary, even if the drugs do not fall in
one of the categories and classes identified in the summary of EHB benchmark information.
After you’ve filled in all RXCUIs for your drug list, complete the “Tier Level” column by
selecting the RXCUI’s cost-sharing tier from the seven tier levels available in the dropdown menu.
If the drug provided in the RXCUI is not part of the given drug list, select “NA.”
The “Prior Authorization Required” field is required if anything other than “NA”
was selected for the RXCUI’s tier level. In this field, indicate whether the drug
requires the prescribing physician to obtain prior authorization before the plan will cover the drug
by selecting “Yes” or “No” from the dropdown. The “Step Therapy Required” field is also
required if you selected anything other than “NA” as the RXCUI’s tier level. Here, indicate whether
the plan requires enrollees to try at least one other drug before the plan covers the given drug.
If you have more than one drug list, select “Add Drug List” at the top of the worksheet.
To remove the most recently created drug list, click “Remove Drug List.”
CMS requests that issuers remove drug lists that are not used. Unused drug lists include
those that are linked to Formulary IDs that do not associate with a Standard Component ID.
Note that drug lists are removed in the reverse order they were created.
If you want to remove a drug list that is not the last one created,
copy and paste the data from the last drug list into the drug list you want to delete,
essentially overriding the data previously there. Then, remove the final drug list.
Once you’ve completed the Drug Lists worksheet, navigate to the Formulary Tiers worksheet.
Click the “Create Formulary IDs” button and enter the number of formularies you intend to associate
to plans in your QHP Application. Click “OK.” In the first cell under the “Formulary ID” column,
use the dropdown to select one of the Formulary IDs the template generated.
The “Drug List ID” field will auto-populate if you only have one drug list.
If you have more than one, select the Drug List ID that should be associated with this Formulary ID.
Next, select the number of tiers in this formulary. This should correspond to the
number of tiers in the selected drug list. A maximum of seven tiers can be
used to describe your formulary; however, you are not required to use all seven.
The next field, “Drug Tier ID” will auto-populate based on your selection in the previous column.
Note that all drugs within the same tier should have the same cost sharing structure.
Next, select “Click here to Select” in the “Drug Tier Type” field. In the dialogue box
that appears, select the drug types that apply for this drug tier. Choose a maximum of two
drug types: one generic and one brand type. Choose “Specialty Drugs” if you only have one
specialty tier. If you have both preferred and non-preferred specialty drugs, create two tiers.
Designate the first as “Specialty; preferred brand” and designate the second as “Specialty;
non-preferred brand.” Differentiate between the two using cost sharing.
Choose “Zero Cost Share Preventive Drugs” if you have a preventive tier. If this is selected,
it is the only type that can be selected for the tier, and the next two elements will auto-populate
with “$0” and “0%” respectively. If you select this tier, please associate it to Tier 1 to
represent the lowest cost tier to the consumer. Choose “Medical Service Drugs” if there are
medical service drugs in your formulary. If this is selected, it is the only type that
can be selected for the tier, and the next two elements will auto-populate with “Not Applicable.”
Note that preventive services under the Patient Protection and Affordable Care Act
must be covered without requiring the consumer to pay a copay, coinsurance, or meet a deductible.
CMS recommends placing these drugs into a separate Zero Cost Share Preventive tier.
Once you select the drug tier type, click “OK” and complete the “1 Month In Network Retail
Pharmacy Copayment” field. If you select one of the dollar value options, input the dollar value
for the copayment. Select “Not Applicable” if the consumer only pays a coinsurance for the tier.
Next, complete the “1 Month In Network Retail Pharmacy Coinsurance” field.
Similar to the previous field, if you select one of the percentage value options,
input the coinsurance rate in the dialogue box that appears.
Select “Not Applicable” if the consumer only pays a copay for the tier.
Note that both the copay and coinsurance for the previous two fields cannot be “Not
Applicable,” unless the drug tier type is “Medical Service Drugs.”
To indicate that a tier has no cost sharing, but it is not labeled as Zero Cost Share Preventive,
select either “No Charge” for the copay and “Not Applicable” for the coinsurance,
or “Not Applicable” for the copay and “No Charge” for the coinsurance.
In the next data element, indicate whether the drug tier offers 1-month out-of-network retail
pharmacy benefits. If you select “Yes,” fill in the information in the next two fields.
Similarly, indicate whether the drug tier offers 3-month in-network mail order pharmacy benefits.
If you select “Yes,” complete the following two data elements.
Finally, indicate whether the drug tier offers 3-month out-of-network mail order benefits.
If you select “Yes” in this field, enter information for the final two columns.
The selections for the copayment and coinsurance fields will be used to
derive the deductible information for each tier,
so be sure to select “after deductible” or “with deductible” when applicable.
Once these fields are complete, continue adding formulary IDs and drug tiers as appropriate,
until all formulary IDs have been entered. Any cost sharing features that cannot be captured
within the template should be explained in detail in any consumer-facing materials.
Now, let’s validate and finalize the template. Once you have completed the template,
click the “Validate” button in the top left corner of the worksheet.
Any data issues in your template that need to be resolved will be displayed; correct these and
click the Validate button again. Continue this process until all errors have been resolved.
Once the template is valid, click the “Finalize” button to create an
XML that will be automatically saved in the same folder as the template.
The XML extract is the file you will submit as part of your QHP Application.
If you have questions regarding your QHP Application, please
contact the Marketplace Service Desk at CMS_FEPS@cms.hhs.gov or 855-CMS-1515.
For more information about the QHP certification process, visit www.qhpcertification.cms.gov.