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Drug benefits must figure into essential coverage package


Prescription coverage is one of the 10 must-have categories, but the details can vary widely among benchmark plans.

Cost is the main concern for the Academy of Managed Care Pharmacy (AMCP), and the academy maintains that specific formulary decisions should be made at the health plan level. CEO Edith Rosato says that if the final essential-benefit rules don't contain enough flexibility, there will likely be an increase in healthcare costs.

While AMCP is not opposed to the guidelines outlined in the Essential Health Benefits Bulletin issued in December, "when you start calling them requirements or standards, you get into a dangerous area." Competition and private-market innovation keep costs manageable, and too many federal mandates can cripple that flexibility, she says.

Older patients are more likely to have compromised functioning of the liver or kidneys for example, so prescribing for them can be more complex for clinicians. Limiting the range of preferred drugs could create higher secondary costs for hospitalizations or emergency room visits.

Biologics are another example where flexibility is key to keeping costs down.

"The newer drugs coming out, especially the biologics, change the paradigm as well," she says. "They're very costly, so a health plan has to balance the use of them versus other drugs on the market to figure out the best drug for a certain patient population. That gets back to the flexibility of being able to create and maintain your own formulary."

In January, Avalere Health, an advisory services company, released a study of benchmark-plan drug benefit formularies to identify how much variation exists among the options. The study compared small group plans in California, Colorado, Maryland and New York against the Federal Employees Health Benefits plan.

The research showed that although there was some variation between the small group plans, each of the four covers a robust number of drugs. For most of the classes in the study, plans covered at least 50% of brand and generic products available in each class.


Bonnie Washington, CEO of Avalere, says the proposed benefit rules give managed care some flexibility, thanks to the provision that health plans can vary formularies as long as they provide at least one drug in each class contained in the benchmark plan. The proposed minimum is one drug per therapeutic class, while Medicare Part D calls for two drugs per class as a minimum.

"Some of the rules about the actuarial value of these benefits are going to cause the plans to have cost sharing that is much higher than what people are used to today," says Washington. "We looked only at what drugs are covered on the formulary, not at what the current cost sharing is versus what it could be."

Rosato says AMCP is asking the Department of Health and Human Services to look at medication therapy management services.

"Research points to the fact that helping a patient manage and understand their medication and stay adherent to it can significantly drive down the cost of healthcare," she says.

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