This data collection effort applies to pharmacy benefit managers (PBM) and health plan issuers.
Health plan issuer data call information
Pharmacy benefit manager data call information
Health benefit plan issuer data call
Reporting period - January 1, 2023, to December 31, 2023
Report due date - March 1, 2024
Background information
Each year, health benefit plan issuers shall file a report to the commissioner as specified by Insurance Code Section 1369.503 concerning prescription drug utilization in the previous calendar year.
The information issuers submit will be made available on our website in aggregate form by June 1 of each year.
Reporting form
Download health benefit plan reporting form (PDF).
FAQs
Is this report for Texas health plans or all plans across the country?
This report collects information on health plans issued under Texas law. Do not include data for plans regulated exclusively by the federal government, such as Medicare and federal Employee Retirement Income Security Act (ERISA) plans.
Do we report data for government-administered health plans such as Medicaid and CHIP?
No. Data reported should be for fully-insured private health plans regulated by TDI.
Do we also report data for clinician-administered drugs?
This report includes both outpatient drugs and clinician-administered drugs.
Does "utilization management" include both clinician-administered drugs and prior authorization of outpatient prescription drugs?
Utilization management in this report includes both clinician-administered drugs and prior authorization of prescription drugs.
How do we determine which drugs are most frequently prescribed?
Please use total number of prescriptions filled or claims paid. Combine instances where the drug was filled at different strengths (for example, 10 mg vs. 20mg).
How do we report generic drugs?
Please combine brand name drugs with their generic equivalents.
There are several questions at the bottom of the health plan reporting form that ask for an answer in percentage terms. How do we calculate this?
These example calculations are based on 2019 as the preceding calendar year:
- The percent increase in annual net spending for prescription drugs.
Suppose net spending on prescription drugs rose from $30 million in 2018 to $33 million in 2019. The percent increase would be ($33 million - $30 million)/$30 million = 10%.
- The percent increase in premiums attributable to prescription drugs.
Suppose net spending on prescription drugs rose from $30 million (2018) to $33 million (2019), while total premiums rose from $155 million (2018) to $165 million (2019). The percent increase in premiums attributable to prescription drugs is ($33 million - $30 million) / ($165 million - $155 million) = 30%.
- The percent of specialty drugs with utilization management.
Suppose there are 600 specialty drugs on a health plan issuer's formulary, of which 150 are subject to utilization management (UM). Then the percent of specialty drugs with UM is 150/600 = 25%.
- The premium reductions attributable to specialty drug UM.
Suppose premiums were $165 million in 2019, but it is estimated that premiums would have been $170 million in the absence of specialty drug UM. The premium reductions attributable to specialty drug UM is $5 million.
Pharmacy benefit manager data call
Reporting periods - January 1, 2022, to December 31, 2022
Report due date - March 1, 2023
Background information
Each year, PBMs shall file a report with the commissioner as specified by Insurance Code Section 1369.502 concerning rebates, fees, and other payments by a PBM in the preceding calendar year.
The information pharmacy benefit managers submit will be made available on our website in aggregate form by June 1 of each year.
Reporting form
Download PBM reporting form (PDF).
FAQs
Is this report for Texas health plans or all plans across the country?
This report collects information on health plans issued under Texas law. Do not include data for plans regulated exclusively by the federal government, such as Medicare and federal Employee Retirement Income Security Act (ERISA) plans.
Do we report data for government-administered health plans such as Medicaid and CHIP?
No. Data reported should be for fully-insured private health plans.
What is a pharmacy benefit manager?
In its statute governing third party administrators, Texas Insurance Code Section 4151.151 defines "pharmacy benefit manager" as a person, other than a pharmacy or pharmacist, who acts as an administrator in connection with pharmacy benefits.
What if a PBM uses a third-party intermediary such as an “aggregator”?
The amount that is “retained as revenue” should be known to the PBM because the statute defines this as the amount that is “retained as revenue by the pharmacy benefit manager.” However, if a PBM uses an aggregator, the aggregator could hold data for the other required amounts that are defined in the statute as “the aggregated rebates, fees, price protection payments, and any other payments collected from pharmaceutical drug manufacturers.” In this case, we suggest that the PBM contact the aggregator for these amounts since they represent what is actually collected from pharmaceutical drug manufacturers.