Washington State Insurance Commissioner Mike Kreidler says a strict generic-only prescription plan is not a real prescription plan.
Kreidler has adopted an emergency rule that bans generic-only drug plans that make no exceptions at all for brand-name drugs.
The rule is set to take effect Aug. 1.
“Some medical conditions require prescription medication for which there is not a therapeutically equivalent generic alternative or for which the generic alternative is not efficacious based on a person’s clinical response,” Kreidler says in an explanation of the rule.
Because of the limits of generic drugs, “a generic-only drug benefit prevents a covered person from being able to use their purchased insurance plan to help pay for medically necessary medicine or drugs, unreasonably restricting their treatment,” Kreidler says.
The rule applies to any health benefit plan with a prescription drug benefit offered or issued in Washington state by a health carrier.
Carriers still can use formulary, or drug list, designs that strongly encourage patients to use generic drugs, and they can limit coverage to coverage for generic drugs when therapeutically equivalent generic alternatives to brand-name drugs are available, Kreidler says.
The federal Patient Protection and Affordable Care Act of 2010 (PPACA) requires the new health insurance exchanges that are supposed to distribute insurance starting in 2014 to offer nonprofit “Navigators” to help consumers understand health care and health insurance.
Health insurance agents and brokers have objected to the Navigator system provision, in part because it’s not clear whether they can be Navigators, how they could be paid to be Navigators, whether Navigators would have appropriate training and licenses, and whether Navigators would compete with agents and brokers.