Doctors say how ACA drug benefits can be strengthened

The proposal's attempt to encourage more generous drug coverage minimums still falls short, organized medicine says, pointing to Medicare Part D as a better standard.

By — Posted Jan. 7, 2013

Print  |   Email  |   Respond  |   Reprints  |   Like Facebook  |   Share Twitter  |   Tweet Linkedin

Organized medicine groups said a proposed federal rule defining benefits requirements under the health system reform law might not provide sufficient prescription drug coverage for patients with chronic conditions. The associations suggested that Medicare's drug benefit, which contains some additional patient protections and has a broader list of covered medications, should serve as a model for formularies offered by insurance plans under the law.

Starting in 2014, qualified plans on health insurance exchanges and some plans outside of the exchanges will be required to cover essential health benefits packages composed of 10 broad categories of services. Each state must choose a benchmark plan from a selection of popular plans in its jurisdiction to determine its essential health benefits package. Many to date have selected the largest small-group plans in their states to serve as their benchmark plans.

The Centers for Medicare & Medicaid Services issued a proposed rule in November 2012 to set policies for states on these benefits, as well as to establish actuarial values for covered plan benefits and accreditation standards for qualified plans on the insurance exchanges. Comments on the proposed rule were due Dec. 26, 2012. In recent guidance, the Dept. of Health and Human Services said it planned to issue a final rule on these provisions of the Affordable Care Act in early 2013.

The rule largely codified initial federal guidance issued in 2011, except that it broadened provisions on prescription drug coverage. Instead of just covering a minimum of one drug per therapeutic class, affected health plans would be required to cover the same number of drugs as a state's benchmark plan. In the event the benchmark doesn't cover any medications in a particular class, plans would need to cover at least one drug in that class.

The revision is more generous than what initially was proposed, opening up the possibility for states “to choose plans that would require two or more drugs in each class,” the Alliance of Specialty Medicine wrote in comments to CMS in late December 2012. But it still would leave room for plans to cover an arbitrary number of drugs, offering no guarantee that patients with serious chronic conditions would have access to the medications they need, the alliance stated.

In particular, the rule falls short of what's offered under Medicare Part D, where all drugs in certain key categories must be covered to prevent insurer discrimination against beneficiaries with significant health care needs, according to the alliance's comments. “Patients may need access to more than one medication from the same class at the same time,” it said.

James L. Madara, MD, executive vice president and CEO of the American Medical Association, gave similar advice about using Part D as a coverage model in the AMA's comment letter to CMS. “Under Medicare Part D, CMS may require more than two drugs for particular categories or classes if additional drugs present unique and important therapeutic advantages in terms of safety and efficacy,” he wrote. Beneficiaries with certain diseases might be discouraged from enrolling in a plan if drugs of this type were absent from the plan's formulary, he stated.

Part D formularies must include “all or substantially all drugs within the immunosuppressant, antidepressant, antipsychotic, anticonvulsant, antiretroviral and antineoplastic classes,” Dr. Madara wrote. The AMA recommended that CMS use the Part D formulary as a template for those six classes of drugs, and that qualified health plans should update their formularies based on methods used by Part D and the private insurance market.

The specialists' alliance requested that all plans be required to meet Part D's standards to ensure adequate drug coverage for newly insured people under the ACA, both through private insurance and Medicaid.

Back to top


AMA requests for essential health benefits

The American Medical Association called for several revisions to a proposed rule that would set policies for states on the Affordable Care Act's essential health benefits provision. The AMA honed in on children's benefits and the scope of the rule's prescription drug coverage. The Association said the Centers for Medicare & Medicaid Services should:

  • Use Medicaid's Early and Periodic Screening, Diagnostic and Treatment program as the model for defining pediatric essential health benefits. The AMA maintains that some benchmark options allowed under the proposed rule fall short of including all medically necessary services for children.
  • Develop a robust appeals and grievance process to ensure that patients have access to needed drugs. It should be based on Medicare Part D's procedures, “which call for an expedited, time-limited process with emergency filling of prescriptions,” the AMA stated.
  • Ensure access to needed physician-administered prescription drugs.

Source: Comments on CMS proposed regulation on Standards Related to Essential Health Benefits, Actuarial Value, and Accreditation, American Medical Association, Dec. 21, 2012

Back to top



Read story

Confronting bias against obese patients

Medical educators are starting to raise awareness about how weight-related stigma can impair patient-physician communication and the treatment of obesity. Read story

Read story


American Medical News is ceasing publication after 55 years of serving physicians by keeping them informed of their rapidly changing profession. Read story

Read story

Policing medical practice employees after work

Doctors can try to regulate staff actions outside the office, but they must watch what they try to stamp out and how they do it. Read story

Read story

Diabetes prevention: Set on a course for lifestyle change

The YMCA's evidence-based program is helping prediabetic patients eat right, get active and lose weight. Read story

Read story

Medicaid's muddled preventive care picture

The health system reform law promises no-cost coverage of a lengthy list of screenings and other prevention services, but some beneficiaries still might miss out. Read story

Read story

How to get tax breaks for your medical practice

Federal, state and local governments offer doctors incentives because practices are recognized as economic engines. But physicians must know how and where to find them. Read story

Read story

Advance pay ACOs: A down payment on Medicare's future

Accountable care organizations that pay doctors up-front bring practice improvements, but it's unclear yet if program actuaries will see a return on investment. Read story

Read story

Physician liability: Your team, your legal risk

When health care team members drop the ball, it's often doctors who end up in court. How can physicians improve such care and avoid risks? Read story

  • Stay informed
  • Twitter
  • Facebook
  • RSS
  • LinkedIn