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AMCP Expresses Serious Concerns over Prescription Drug Coverage Changes in Proposed Rule on Essential Health Benefits

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ALEXANDRIA, Va., Nov. 27, 2012 /PRNewswire-USNewswire/ -- The Academy of Managed Care Pharmacy (AMCP) has serious concerns about a proposed rule from the Obama Administration that could significantly expand the number of prescription drugs that must be covered as an essential health benefit (EHB) under the Affordable Care Act starting in 2014.

While AMCP supports access to appropriate medication therapies, this access must be balanced with cost considerations to ensure the affordability of the entire benefit, a point that was made in an October 2011Institute of Medicine (IOM) report, "Essential Health Benefits: Balancing Coverage and Cost."

The EHB proposed rule, issued Nov. 20, 2012, represents a significant departure from a December 2011 "EHB bulletin" as it pertains to the issue of prescription drug coverage. Last year's bulletin from the Department of Health and Human Services (HHS) required plans to offer only one drug per category and class. The 2011 bulletin also described HHS' approach to balancing costs, comprehensiveness and accessibility of EHBs as recommended by the October 2011 IOM report.

By contrast, under the new EHB proposed rule, plans starting in 2014 would be required to provide at least the greater of: (a) one drug in every category and class or (b) the same number of drugs in each category and class as the "benchmark plan" – i.e., the plan selected by state officials as representing a typical employer plan in that state. Under this standard, if a benchmark plan offers more than one drug per category and class, then all plans would have to have at least the number of drugs in the benchmark plan.

"This rule would restrict the ability of health plans to design pharmacy benefits that are scientifically based and financially prudent for their member populations, as outlined in the IOM report," said AMCP Chief Executive Officer Edith A. Rosato, RPh, IOM. "Just because a benchmark plan offers multiple drugs in a category does not automatically mean that these are the most effective and appropriate medicines. Yet, this rule could require all plans to offer multiple products for coverage even when it is not warranted."

Rosato continued, "AMCP has long contended that plans should have the flexibility to design effective benefits through their pharmacy and therapeutics committee's evaluation of medicines, and not through a regulated category and classification structure. This gives plans the ability to provide the best value and choice to patients."

On another pharmacy related topic, the 2012 proposed rule for EHBs requires plans to report "drug lists" (the term formulary is not used) to government entities using the United States Pharmacopeia's (USP) classification system. In earlier comments, AMCP had opposed being restricted to using one classification system with a single compendium.

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"Requiring the use of the single classification system may impose an undue obstacle on the development of appropriately evaluated and valid formularies," said Rosato. "We will continue to express our concerns with this rule and explain our position to HHS officials."

These and other regulations regarding prescription drug coverage were part of the proposed rule on standards of coverage for EHBs. This rule, in turn, was one of three proposed rules published Nov. 26 that will guide the establishment of qualified health plans participating in state health insurance exchanges, as well as non-grandfathered individual and small group plans under the ACA beginning in January 2014.

AMCP is carefully reviewing all of the proposed rules and will provide comments by the Dec. 26, 2012, deadline.

About AMCP

The Academy of Managed Care Pharmacy (AMCP) is a national professional association of pharmacists and other health care practitioners who serve society by the application of sound medication management principles and strategies to improve health care for all. The Academy's more than 6,000 members develop and provide a diversified range of clinical, educational and business management services and strategies on behalf of the more than 200 million Americans covered by a managed care pharmacy benefit. AMCP will celebrate its 25th anniversary in 2013. More news and information about AMCP can be obtained on its website, at


SOURCE Academy of Managed Care Pharmacy



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