Health benefit plan issuer reporting form

Health benefit plan issuer reporting form

HBPI | 0126
Instructions
- Under Texas Insurance Code Section 1369.503, the report is due by March 1 of each year.
- More information about this report is located on the pharmaceutical benefits reporting index page.
- Please list the 25 most frequently prescribed drugs across all fully insured commercial plans in aggregate. The most prescribed drug should be in the first field.
- Each drug should appear only once.
- Please use the generic form of each drug without dosage or drug formulation details. For example, use “Acetaminophen” instead of “Tylenol”.
- Please use the short name of a drug instead of the salt form unless a meaningful difference exists between them. For example, use “Atorvastatin” instead of “Atorvastatin Calcium”.
- All fields marked with * are required and must be filled.
Company information
Company name*
NAIC number
TDI number
Company address
Company address*
Company city*
Company state*
Company zip*
Contact information
Contact name*
Contact title*
Phone number*
Email address*
My address is the same as the company address

Yes, my address is the same as the company addressNo, my address is different and I will enter my address below
Release my email address

Yes, TDI may release my email addressNo, TDI may not release my email address
Contact address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Most frequently prescribed drugs
Reporting year*
Which calendar year does this report include?
Please list the 25 most frequently prescribed drugs across all fully insured commercial plans in aggregate. The most prescribed drug should be in the first field. Each drug should appear only once. Please use the generic form of each drug without dosage or drug formulation details. For example, use “Acetaminophen” instead of “Tylenol”.
1 Most prescribed drug
2 Most prescribed drug
3 Most prescribed drug
4 Most prescribed drug
5 Most prescribed drug
6 Most prescribed drug
7 Most prescribed drug
8 Most prescribed drug
9 Most prescribed drug
10 Most prescribed drug
11 Most prescribed drug
12 Most prescribed drug
13 Most prescribed drug
14 Most prescribed drug
15 Most prescribed drug
16 Most prescribed drug
17 Most prescribed drug
18 Most prescribed drug
19 Most prescribed drug
20 Most prescribed drug
21 Most prescribed drug
22 Most prescribed drug
23 Most prescribed drug
24 Most prescribed drug
25 Most prescribed drug
The percent increase in annual net spending for prescription drugs across all plans in the preceding calendar year*
Must be a number without the % sign. Please round to the nearest decimal, e.g., 123.5 for 123.45%.
The percent increase in premiums that were attributable to prescription drugs across all plans in the preceding calendar year*
Must be a number without the % sign. Please round to the nearest decimal, e.g., 123.5 for 123.45%.
The percentage of specialty drugs with utilization management in the precedingcalendar year*
Must be a number without the % sign. Please round to the nearest decimal, e.g., 123.5 for 123.45%.
The premium reductions in dollars that were attributable to specialty drug utilization management in the preceding calendar year*
Must be a number without the $ sign in dollars. Please enter 123 for $123.45.
Should be Empty:

Health benefit plan issuer reporting form

Instructions

Company information

Company address

Contact information

Most frequently prescribed drugs