ProCare Rx Receives Full Certification from the Centers for Medicare and Medicaid Under 2025 Prescription Drug Event (PDE) Data Submission Guidelines
The ProCare Rx Team • November 26, 2024
ProCare Rx, a leading pharmacy claims processor, has received updated certification from the Centers for Medicare and Medicaid (CMS) 2025 Prescription Drug Event (PDE) data submissions beginning January 1, 2025. Our certification covers both the Traditional Medicare and Medicaid Plans as well as the Program of All-Inclusive Care for the Elderly (PACE) Medicare Part D. As one of the first dual-compliant providers, our customer regulatory reporting will continue to meet both current and new 2025 submission requirements.
This program-wide recertification was mandated by CMS, and included significant changes in the PDE File Layout expansion and introduction of new financial and non-financial data fields on the PDE record.
Some of the changes applicable to all Part D sponsors include:
- “Vaccine Administration Fee or Additional Dispensing Fee” (This removed reference to Emergency Use Authorization (EUA) status of oral antiviral drugs)
- “Drug Status Indicator,” determines that the National Drug Code (NDC) submitted on the PDE was an applicable drug or non-applicable drug at the time of PDE processing.
For PACE claims there are a variety of additional financial/non-financial fields and indicators that must be included in a claim:
- Estimated Remuneration at POS Amount (ERPOSA)
- Pharmacy Price Concessions at POS
- Patient Pay Amount
- Patient Liability Reduction Due to Other Payer Amount (PLRO)
- Other TrOOP Amount/Indicator
- Selected Drug Subsidy
- Reported Manufacturer Discount
- Gross Drug Cost Below Out-of-pocket Threshold (GDCB)
- Gross Drug Cost Above Out-of-pocket Threshold (GDCA)
- Low Income Cost Sharing Subsidy Amount (LICS)
- Non-covered Plan Paid Amount (NPP)
- Originally Prescribed Quantity
- Part D Model Indicator
- Medicare Prescription Payment Plan Indicator
Kristi Mitchell, ProCare Rx Vice President of Product Management and Implementation stated, “This certification is a testament to our team’s hard work and dedication. The journey to ensuring that we are able to meet the new CMS reporting requirements on behalf of our clients has been incredibly rewarding, and we express our sincere gratitude to all our clients, employees, and everyone in the ProCare Rx family for their continued support. We look forward to achieving many more milestones together in the future!”
The 2025 PDE Testing and Certification Protocol for non-PACE Part D sponsors is posted at www.csscoperations.com
About ProCare Rx
ProCare Rx is a privately held, independent pharmacy benefit manager (PBM) that has empowered healthcare and self-insured organizations since 1988. We provide fully integrated, in-house solutions—including claims adjudication, clinical program design, pharmacy network access, cost containment, and data analytics—all supported in the U.S. Our flexible, transparent model serves self-insured employers, third-party administrators (TPA), brokers, health plans, health systems, managed care organizations (MCO), unions, workers’ compensation programs, Medicare, Medicaid, hospices, and other PBMs. With a proprietary technology platform, commitment to ethical operations, and a focus on lowest net cost, ProCare Rx delivers long-term value, clinical performance, and trusted pharmacy benefit partnerships.
Media Contact:
Marc Cohen, VP, Marketing and Sales
marketing@ProCareRx.com
Drug costs continue to surge, regulatory winds are shifting, and employers are bracing for steeper expenses ahead. Now more than ever, your choice of PBM partner can be a major differentiator or a liability. Why This Moment Matters Cost growth expectations are steep. Employers are forecasting higher health care costs in 2026, with pharmacy spend as a central contributor. Some projections suggest pharmacy alone may rise by double digits next year, far outpacing general medical cost trends. Reform pressure is building. PBM practices are under increasing scrutiny. Policymakers, physician groups, and pharmacy organizations are pushing for reforms that would delink PBM profits from drug list prices, increase transparency, and ensure savings flow to plan sponsors and patients. PBMs themselves are already floating proposals to adjust their practices ahead of possible legislation. Regulation is becoming inconsistent and complex. While federal courts and Congress weigh in, states continue to pass new PBM laws. For multi-state employers, this means navigating a patchwork of rules that can be confusing, sometimes conflicting, and potentially at odds with fiduciary obligations. What to Look for in a PBM Partner Given this evolving landscape, employers should place extra emphasis on: Regulatory agility and compliance support Your PBM must help you navigate both federal and state-level requirements, protecting your plan against compliance risk. True cost transparency and incentive alignment Demand clarity on how your PBM is compensated. Incentives should be aligned with your plan, not tied to higher drug list prices or opaque rebate arrangements. Formulary integrity and clinical governance With expensive therapies hitting the market, your PBM should balance cost savings with clinical appropriateness, ensuring members receive the right drug, not just the cheapest option. Benefit design flexibility Rising costs require innovative plan designs such as specialty carve-outs, differential cost-sharing, or utilization management. Your PBM should be a partner in shaping these strategies, not a barrier. Member experience and adoption tools With members facing higher cost-sharing and more complex therapies, digital tools, adherence programs, and proactive engagement are essential for better outcomes. Proven performance and benchmarking In this climate, results matter. Your PBM should demonstrate measurable cost savings and clinical outcomes year over year, benchmarked against peers. The Bottom Line Plan sponsors are entering a pivotal moment. The forces shaping pharmacy benefits include cost escalation, regulatory change, and clinical complexity. The status quo will not be enough. Choosing a PBM partner with regulatory foresight, aligned incentives, clinical integrity, and member-centric tools can help employers navigate this era, mitigate risk, and deliver sustainable value to their workforce. Sources Reuters – Pharma middlemen propose regulatory changes to avoid Trump administration rules Pharmacy Times – Pharmacy policy updates for September 2025 Bloomberg Law – Drug benefit compliance is a state-by-state test for sponsors NASPA – Over 100 pharmacy organizations urge PBM reform AMA – Advocacy update spotlight on PBMs Healthcare Dive – Employers expect 9% higher health costs in 2026 WorldatWork – Business Group on Health predicts 9% higher healthcare costs in 2026 PwC – Behind the numbers: Rising drug spend ProCare Rx PBM 101 video script
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