The $64,000 Question
Can a plan exclude specialty drugs? The answer is yes. Many PBM’s limit their specialty drug formularies. But, can a plan eliminate all specialty drugs and remain ACA compliant?
We don’t know the answer to this. One PBM we have talked to says yes. Three others we talked with say no. One more indicated they did not know and would have their legal department check into it (We are still waiting).
In searching the internet we find nothing that addresses this question other than one article that stated “It is rare an insurer eliminates all specialty drugs.” So, does that mean some do? Apparently so.
Specialty drugs are bankrupting self-funded health plans. Plan sponsors don’t know what to do other than to throw up their hands, discontinue their employee health plan and give employees a raise instead.
If you know the answer to “Can a plan sponsor completely eliminate specialty drugs and remain ACA compliant” write to RiskManager@RiskManagers.us. We will post your comments here.
Molly Mulebriar – Waring, Texas
According to guidance issued by the Centers for Medicare & Medicaid Services, a prescription drug plan is deemed to be creditable if it:
1. Provides coverage for brand and generic prescriptions;
2. Provides reasonable access to retail providers and optionally for mail order coverage;
3. Is designed to pay on average at least 60% of participants prescription drug expenses;
4. HAS A MAXIMUM ANNUAL BENEFIT PAYABLE BY THE PLAN OF AT LEAST $25,000
Is # 4 a loophole to be exploited?
Email from broker to PBM after reviewing PBM Monthly Executive Summary Report
Bill, we can find nothing that stipulates that specialty Rx has to be covered. The ACA does require drugs in each therapeutic class to be covered but we can’t find where they have to be the specialty drugs. Seems that we are trying to prove a negative and as you and I both know that is very hard to do.
Here is a little non-legal language I was able to find. This is from Caremark.
By mandating that prescription drugs are one of 10 essential health benefits that insurance plans must offer — among maternity and newborn care, preventative care, hospitalization and mental health — the ACA makes drug coverage a core part of health insurance, and it eliminates insurers’ ability to tack on a prescription drug benefit plan to a health care plan at an additional cost.
The ACA requires insurance plans to cover at least one drug in every category and class in the U.S. Pharmacopeia, the official list of approved medicines. Moreover, patients — and their doctors — can request and gain access to clinically appropriate drugs that aren’t covered.
Plans maintain their own preferred-drug lists, or formularies, and the cost for the same drug can vary significantly between plans, which is especially important to note for consumers with chronic conditions.
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