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What the Obamacare Health Insurance Rules Mean for Pharmacy

Rules issued for the Affordable Care Act outline PBM requirements


Drug coverage rules have been issued under the Affordable Care Act.

PBMs managing pharmacy benefits for Obamacare-compliant health insurance plans must cover at least one medication from each USP drug category.

Photo courtesy of CDC/Amanda Mills

On Nov. 20, 2012, the U.S. Department of Health and Human Services issued three sets of proposed regulations that provided the clearest picture yet of what health insurance plans will cover when the Patient Protection and Affordable Care Act mandate for nearly all Americans to have health coverage takes effect on New Year's Day 2014.

Most of the rules had been issued in some form months or years earlier, but the updated and expanded information clarifies issues such as requiring "platinum" plans to cover 90% of enrollees health care costs. The rules also make clear what constitutes the baseline minimum of benefits a plan can provide and still meet the definition of a qualified health plan.

The specifics of each regulation are available online and open for public comment until Dec. 26, 2012. For reasons discussed below, however, the rules specific to pharmacy benefits seem unlikely to change much before being finalized and taking effect.

Basic Rules for Health Insurance Plans Under Obamacare

The heart of the health insurance regulations for implementing the law popularly known as Obamacare lies in their definition of essential health benefits. Ten EHBs are listed:

  1. Ambulatory patient services
  2. Emergency services
  3. Hospitalization
  4. Maternity and newborn care
  5. Mental health and substance use disorder services, including behavioral health treatment
  6. Prescription drugs
  7. rehabilitative and habilitative services and devices
  8. Laboratory services
  9. Preventive and wellness services and chronic disease management
  10. Pediatric services, including oral and vision care

How any given plan provides those EHBs can vary, as can allowable monthly and annual premiums, co-payments and cost-sharing arrangements.

Pharmacy Benefits Under Obamacare-Compliant Plans

The EHB list was developed and promulgated to ensure that every health insurance plan offered through an Affordable Insurance Exchange provides adequate and roughly equal coverage. To further achievement of that goal, state or federal exchange administrators must designate a benchmark plan whose provisions every other plan in the state must match or exceed.

In terms of prescription drug coverage, this means that each private health insurance plan offered through an employer or purchase from an exchange must cover at least one medication in each of the 50 drug categories defined by the U.S. Pharmacopeia. When drug categories comprise more than one class and/or formulary key drug type, at least one of those medications must also be covered. Additionally, if the benchmark plan in a state covers more than one drug in a category, class or type, all plans in the state must do so.

Medicare Part D prescription drug plans and Medicaid formularies should not change under the Obamacare rules because each of those programs already cover practically every medication approved or licensed by the U.S. Food and Drug Administration.

One fine-print provision of the pharmacy benefit rule worth highlighting is that each covered drug in category must be a chemically or biologically distinct product. Also, qualified health plans must make provisions for enrollees to obtain and afford properly prescribed medication that are not on the standard formulary.

Mark Your Calendars With Obamacare Implementation Dates

Implementation of the Obamacare law began within days of its enactment on March 23, 2010, and will continue through 2014. The full timeline of when provisions took, or will take, effect is available at Healthcare.gov. Upcoming dates that all pharmacists, student pharmacists and pharmacy technicians should prepare for include

  • Jan. 1, 2013 -- State Medicaid program can receive grants to expand preventive care like vaccines and diabetes screening.
  • Jan. 1, 2013 -- "Bundling" of Medicare claims from pharmacists, doctors, surgeons and other health care providers who coordinate treatments for the same patient will be encouraged as the norm. The Centers for Medicare & Medicare Services has been supporting formation of accountable care organizations and medical/health homes for this purpose.
  • October 2013 -- People required to purchase coverage through a health insurance exchange can begin doing so.
  • Jan. 1, 2014 -- Nearly all Americans must carry health insurance or pay a monetary penalty.
  • Jan. 1, 2014 -- Small businesses such as independent pharmacies and home health care practices can begin claiming new tax credits for subsidizing employees' health insurance.

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