Can A Health Plan Exclude Specialty Drugs?


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 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;


Is # 4 a loophole to be exploited?


Email from broker to PBM after reviewing PBM Monthly Executive Summary Report

Image result for acne
“Oh My God, a Freaking $1,800 Zit!”
“I noticed one claimant taking a $1,878.17 (30 day supply for Absorica) for acne?  This is ridiculous. I bet the damn patient doesn’t know what this damn drug costs. And if she does, she doesn’t care because she is using other people’s money. Drug costs are bankrupting health plans.”  
T. Taylor, Insurance Consultant