CLOSE HOLD – DO NOT SHARE – INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law. Prescription Benefit Mandates of the Affordable Care Act May 19, 2015 1 Designing Non- Discrimination Formulary Drug Reviews
Transcript
CLOSE HOLD – DO NOT SHARE – INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full
extent of the law.
Prescription Benefit Mandates of the Affordable Care Act
May 19, 2015
1
Designing Non-Discrimination Formulary Drug Reviews
CLOSE HOLD – DO NOT SHARE – INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosedand may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized toreceive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.
• ACA –Patient Protections and the Health Care Law
• Prescription Drugs- an Essential Health Benefit
• A New Way to Skirt the Denial of Pre-Existing Conditions Rule
• Health Plan Formulary Reviews
• Conclusion- Future Reviews
• References
Agenda
2
CLOSE HOLD – DO NOT SHARE – INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosedand may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized toreceive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.
• Preventive Drugs at No Cost
• Pre-existing Conditions (Non-Denial) Prescriptions Drugs an Essential Health Benefit
• Health Plan Shopping Transparency
• Insurance Coverage Non-Cancellation
• Benefit -No Discrimination
ACA Patient Protections
3
Essential Health Benefit –Rx Drugs
• Ambulatory Patient Services;
• Emergency Services; Hospitalization;
• Maternity and Newborn Care;
• Preventive services ;
• Pediatric services
• Mental Health and Substance use Disorder Services;
• Behavioral Health Treatment;
• Prescription Drugs Coverage
4
Denial of Coverage-The Latest Trends
5
• Specialty/Mail order Prescription Drug Access
• Office of Civil Rights Complaints
• Birth Control- All 18 FDA-Approved Forms Must be Covered
Key Prescription Benefit Related Legislation
6
•
• 45 C.F.R. 156.122, requires health plans cover at least the greater of: (1) one drug in every USP category and class, or (2) the same number of Rx drugs in each category and class as the EHB state benchmark plan formulary.
• 45 C.F.R. part 156.225 prohibits Qualified Health Plan (QHP) issuers from using marketing practices or benefit designs that will discourage the enrollment of individuals with significant health needs.
• Regulation 45 CFR 156.125 prohibits insurers from adopting benefit designs or implementing benefit designs that discriminate based on age, expected length of life, disability, medical dependency, quality of life, or other health conditions
Health Plan Formulary Reviews
7
• Drug Count Tool
• Formulary Outlier Tool
• Clinical Appropriateness Tool
• Treatment Protocol Calculator (New for this year)
Category Class Drug Count Tool
8
Tests for meeting the EHB standards to cover at least the greater of:
(1) one drug in every USP category and class, or (2) the same number of prescription drugs in each USP category and class as the EHB benchmark plan
Identifies categories and classes that do not meet the EHB Benchmark Count,
Generates the count of chemically distinct drugs that are submitted on a given drug list for each USP category and class.
CLOSE HOLD – DO NOT SHARE – INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosedand may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized toreceive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.
Drug Count Tool
9
CLOSE HOLD – DO NOT SHARE – INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to
receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.
Non-Discrimination Clinical Appropriateness Tool
10
• Analyzes the availability of drugs associated with four conditions (diabetes, rheumatoid arthritis, bipolar disorder, and schizophrenia)
• Ensures plans are offering a sufficient number and type of drugs needed to effectively treat these conditions and are not restricting access by lack of coverage or inappropriate use of utilization management techniques
CLOSE HOLD – DO NOT SHARE – INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to
receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.
Clinical Appropriateness Tool
11
Non-Discrimination Formulary Outlier Tool
12
Identifies plans that have unusually high numbers of restricted drugs subject to utilization management restrictions in specific categories and classes when compared to other plans at the state and national level.
CLOSE HOLD – DO NOT SHARE – INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosedand may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized toreceive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.
Formulary Outlier Tool
13
Pharmacological Therapy Protocol
CLOSE HOLD – DO NOT SHARE – INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosedand may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized toreceive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.
CLOSE HOLD – DO NOT SHARE – INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosedand may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized toreceive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.
• Data Integrity
• Patient Access to formulary
• Machine Readable Website
• Adverse Tiering/Risk Adjustment (proposed)
• Preventives/Birth Control (proposed)
Post Certification Analysis Formulary Reviews
16
References
• CMS has posted the review tools, the EHB Rx Crosswalk, and a reformatted RxNorm database in the following locations:
Insurers' Drug Tiering Can Keep Sickest Patients Away
http://www.medscape.com/viewarticle/838896
18
NHeLP and The AIDS Institute Complaint to HHS Re HIV/AIDS Discrimination by Florida Insurershttp://www.healthlaw.org/publications/browse-all-publications/HHS-HIV-Complaint
Consumer group sues Cigna, says mail-order drug policy discriminates against people with HIVhttp://www.usnews.com/news/us/articles/2015/04/28/consumer-group-sues-cigna-alleges-discrimination
CLOSE HOLD – DO NOT SHARE – INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosedand may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized toreceive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.
