Updated research request forms and data security approval requirement effective 4/24/23
SAS Name
GAP_INNPP_COINS_AVG_1M
This variable identifies the average expected cost-sharing amount in dollars for beneficiary co-insurance for a 1 month supply of the drugs on this tier, using an in-network non-preferred pharmacy (INNPP; also known as a standard retail pharmacy within a split network) during the coverage gap phase of the Part D benefit.
This variable will only be populated if the plan has an enhanced benefit design with extra coverage in the gap. Plans that use a co-payment amount rather than a coinsurance percentage will not have a value in this field. The coverage gap is technically referred to as the initial coverage limit (ICL) for the Part D benefit.
CMS instructed plans to calculate this amount by including the average expected cost-sharing amount in dollars that a beneficiary would be expected to pay at a network retail pharmacy for a one month supply of drugs. This estimate should be based on available plan data (such as the most current 6 months of PDE data) for retail pharmacies only. Neither retail extended day supply nor mail order location data should be included in the estimate.
Starting in 2016, CMS changed how they describe pharmacy networks. The INNPP are currently referred to as standard retail pharmacies within split networks. There is no change in the meaning of the variable, and the data values are the same over time.
The CCW constructs the Plan Characteristics File from information submitted by plan sponsors to CMS’s Health Plan Management System (HPMS).
Employer and National Program of All-inclusive Care for the Elderly (PACE) plans are waived from reporting Plan Benefit Package information.
For those plans that did not report, the value of this variable will be blank.
Source: CMS (HPMS Files)