How to Use the Category & Class Drug Count Tool
Did you know that CMS provides review tools that issuers and
states can use to prepare for the QHP Application process?
These review tools allow you to check for errors within your QHP Application
that would result in corrections after submission. Issuers are encouraged to use these tools
to identify and correct data errors prior to submitting application data
in order to reduce the number of required corrections identified during CMS’ reviews.
States are encouraged to use these tools during their reviews to identify potential
errors in their issuers’ application data that would require issuers to make corrections.
The Category & Class Drug Count Tool, or Drug Count Tool for short, helps ensure
that health plans meet the prescription drug essential health benefit, or EHB, requirement.
Issuers offering products and plans market-wide can use the Drug Count Tool to review their
health plans; this tool is not specific to those submitting QHP Applications to CMS.
Issuers are required to include a list of covered prescription drugs for QHPs they intend to offer.
QHPs must cover at least one drug in each United States Pharmacopeia, or USP, category and/or
class, or meet the Essential Health Benefit, or EHB, Benchmark plan requirements in their state if
the benchmark requires a greater number of drugs. To use the Drug Count Tool, you must have
a populated Prescription Drug Template. However, for the tool to work most effectively,
you’re highly encouraged to use a populated Master Review Tool,
with data from the Plans & Benefits Template. While use of the Master Review Tool is not
required, it allows the Drug Count Tool to remove any drug lists included in the Prescription Drug
Template that are not associated with a plan. By importing Master Review Tool data, you will also
be able to see your review results at the plan level, not just the formulary or drug list level.
To download the Category & Class Drug Count Tool, visit the Review Tools
webpage of the QHP certification website and click on the Drug Count Tool link.
Once downloaded, open the tool in Excel, and enable macros.
Read the “Instructions” tab carefully before beginning.
Step 1 asks if you have separate Individual and SHOP Prescription Drug Templates.
If you or your issuer submit data through the System for Electronic Rates & Forms Filing,
or SERFF, and have separate templates for Individual and Small Business Health
Options Program, or SHOP, market plans, select “yes.” Otherwise, leave the selection as “no.”
If you selected “yes,” be sure to follow the template naming convention described in step 1.
In step 2, select the benchmark state using the drop-down menu
under “State Benchmark Selection.” In Step 3, you have the option to
import a Master Review Tool to populate the Drug Count Tool with Plans & Benefits data.
Again, it’s highly recommended you use a Master Review Tool when running the Drug Count Tool.
To complete this step, click the “Import Plans & Benefits Data from Master Review Tool” button.
In Step 4, click the “Run Category & Class Drug Count Review Tool” button
and select the folder in which the Prescription Drug Templates can be found.
Running the tool could take several minutes depending on how much data is processing.
The tool will populate several tabs that provide
more detail on your Drug Count Tool review results.
On the “Output Description” tab, you will find an explanation of the information on the
“Issuer Summary,” “Plan Summary,” “Plan Details,” "All RXCUIs Submitted,"
“Category Class Summary,” “Category Class Details,” and “Substitute RXCUIs” tabs.
The “Category Class Summary” tab identifies the categories and classes with a drug count
that do not meet the EHB benchmark count. If a category and class row is bolded with red font,
it does not meet the EHB benchmark count or the Reevaluated benchmark count.
The “Met? (Yes/No)” columns will indicate: Yes, meaning the drug count meets the
state EHB benchmark count, Yes – Reevaluated, meaning
the drug count meets the Reevaluated benchmark count, but not the state EHB benchmark count, or
No, meaning the drug count does not meet the state EHB benchmark count.
The “Yes – Reevaluated” designation is used when meeting the EHB benchmark count for a category
and class is impossible because the number of available chemically distinct drugs in the EHB
Rx Crosswalk has decreased for that category and class.
To pass this review, you need a result of “Yes” or “Yes-Reevaluated” in the “Met? Yes/No” columns.
If you received a result of “No” in any of these columns,
the issuer will need to make corrections to its data until it passes the review.
The “Category Class Details” tab provides a list of every chemically distinct drug that appears
in the EHB Rx Crosswalk. A row will contain the words “Not Covered” in bold, red font if
it is missing from the drug list that’s being reviewed. Use this tab to identify where RXCUIs
can be added to meet the EHB benchmark counts for the categories and classes that were insufficient.
The “All RXCUIs Submitted” tab provides information on all RXCUIs included on the
prescription drug templates the tool reviewed. For each drug list, this tab identifies whether
the drug is covered, not covered, or not on the prescription drug template.
The “Substitute RXCUIs” tab identifies any RXCUIs which contain chemically distinct
drugs that are not covered in categories and classes where the EHB benchmark requirement
was not met for a given drug list. The Drug Count Tool will also populate an
“Issuer Summary” tab. If you imported data from the Master Review Tool, you will also see the
“Plan Summary” and “Plan Details” tabs. These tabs are based on the results of the Drug Count review,
and will display review results at the issuer, plan, and correction level.
Using the information provided in the summary and detail tabs,
you can identify where RXCUIs can be added to meet the EHB Benchmark Counts
for the categories and classes that did not meet the review requirements.
If there are no drugs available, or if you believe a covered drug should be counted towards meeting
a specific category and class, CMS recommends issuers submit justifications with their QHP
Applications for that category and class. Once the errors that need to be corrected
are identified, issuers will need to correct the data in their Prescription Drug Template.
Issuers should open the template, add the appropriate RXCUIs, and validate and finalize it.
Reimport the updated Prescription Drug Template into the Drug Count Tool,
rerun the tool, and repeat the review process until the tool shows there are a sufficient number
of RXCUIs in the categories and classes for which issuers do not plan to submit a justification.
An issuer’s drug list may be found to be deficient in one of the USP categories and
classes in the following two example scenarios: If the issuer indicates that a drug in the USP
category and class EHB benchmark plan is covered under the medical benefits.
The justification for this correction will only be accepted if the issuer
provides documentation that the drug is actually covered under the medical plan,
or if the review team independently determines the drug is covered under a medical benefit.
If the issuer indicates that a drug in the USP category and
class benchmark plan has been discontinued, the justification for this correction may be
unacceptable if the drug is available in another formulation, for example,
if the liquid form of the drug was discontinued, but the drug is available as a tablet.
If you have questions regarding the QHP Application Review Tools,
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.