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Life Health > Health Insurance

Patient groups: Ban mid-year drug coverage cuts

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Patient, patient and consumer groups want state insurance regulators to curb moves by health plans to cut drugs out of “formularies” — covered drug lists — in the middle of the year.

Groups are asking the Regulatory Framework Task Force, an arm of the Health Insurance and Managed Care Committee at the National Association of Insurance Commissioners (NAIC), to include a provision banning most mid-year formulary cuts when it revises a 13-year-old prescription drug benefits model.

The NAIC approved the model, the Health Carrier Prescription Drug Benefit Management Model Act (Number 22), in 2003.

See also: Regulators Parse New Rx Law

As of October 2012, California, Rhode Island and South Dakota had passed model drug benefits laws influenced by the NAIC model, according to an NAIC model status report. No other states had passed laws based on the model.

In November, the NAIC decided to conduct a formal review to see whether it ought to update the model.

C.M. Gallagher wrote on behalf of America’s Health Insurance Plans (AHIP) to say the NAIC could probably improve the model by making a few changes to model act language or drafting notes.

Jessica Waltman, a consultant who wrote on behalf of the National Association of Health Underwriters (NAHU), wrote to say that NAHU wants regulators to support plan efforts, such as use of different tiers benefits for different types of drugs, to hold drug coverage costs down.

NAHU does not believe updating the drug benefits model should be a top priority, “particularly given its limited adoption across states,” Waltman writes.

A group of 24 of the people appointed to represent consumers in NAIC proceedings suggested in a comment letter that there have been many changes in the health care marketplace since the model was adopted. The consumer reps are asking for changes related to coverage for patients who participate in clinical drugs; restrictions on drug benefits tiers that may discriminate against people with chronic conditions; formulary exception requests and appeals; and mid-year formulary cuts.

“We urge the subgroup to prohibit mid-year formulary changes, absent very specific, limited exceptions,” the reps write.

See also: What consumer reps wish they knew about health plans

Lawrence La Motte has written on behalf of the Immune Deficiency Foundation, a group that speaks for about 250,000 U.S. residents who suffer from immune system disorders, to say that the foundation would like to see the NAIC model include a ban on any mid-year formulary changes, other than moves to add drugs introduced in the middle of the year.

The model does include formulary disclosure requirements, but “such disclosure requirements are rendered less helpful when formulary information can change at any time, even after a consumer has made an informed decision to enroll in a certain plan based on its formulary design,” La Motte writes. 

Other patient groups also asked for bans or tight restrictions on mid-year formulary changes.

See also:

Lawmakers propose Medicare plan network stability standards

WellPoint Unit Develops 4-Tier Drug Benefits Strategy


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