Is Your Rx Plan Over Compliant and Costly?



By William Rusteberg

What constitutes minimum compliance under the Rx minimal essential benefit mandate? Minimum requirements are set by each state. In Texas the minimum benchmark is the BCBS Best Choice PPO – RS26 plan.

According to 45 CFR 156.122, to offer essential health benefits, health plans must cover at least the greater of (1). one drug in every USP therapeutic category and class or (2) the same number of drugs in each USP category and class in the state’s benchmark plan.

Does your current Rx plan comply or does it over-comply, i.e., more expensive than it is mandated to be? For example, if your current plan covers 20 different medications for a given category when only 10 is the required minimum mandated number, you may want to remove 10 of the more expensive medications from that class.

With drug costs accounting for as much as 25% of a plan sponsor’s spend, it may make sense to develop a Minimum Compliant Rx Plan utilizing the least expensive drugs in each therapeutic category and class. Minimum compliance benefits for Texas can be found here – texas-ehb-benchmark-plan (pharmacy is the last five pages).

It may make even more sense to subject Rx benefits to a deductible and eliminate co-pays. Consumers would be required to pay cash up front for drugs at the point of sale before filing  a claim like in the old days.  The shoe box effect, along with the behavioral effect of  “skin in the game” at the point of sale should reduce claims even further. Of course our PBM friends won’t like this idea. Neither will HR directors.