Take Two of These, and Call Me in the Morning

Americans hear a lot about prescription medications. Since the mid-1980s, when direct-to-consumer advertising of prescription drugs first started, advertisements that tell us to ask our doctors “if [name of medication] is right for you” have become a staple of television. Print ads often take up several pages in magazines, and pop-up internet advertisements offer us ways to get our medicines cheaply and quickly.

Insurance coverage for prescription drugs is one of the essential benefits that must be offered by an ACA compliant health insurance policy. The regulations implementing the ACA list two ways for determining which drugs a compliant plan must cover.

The first way is for a plan to provide coverage for at least one drug in every United States Pharmacopeia (USP) category and class, or the same number of prescription drugs in each category and class as the state benchmark plan, whichever is greater. As of 2014, there are 167 USP categories and classes.

As an alternative to the USP categories and classes, or the formulary list of the state’s benchmark plan, a plan may submit its formulary drug list to the Department of Health and Human Services for approval. For plan years beginning on or after January 1, 2017, a pharmacy and therapeutics (P & T) committee would establish and review the plan’s formulary list. P & T committees will be required to meet at least quarterly, have a majority of members who are physicians, pharmacists, or other health care professionals, and must base its “clinical decisions on the strength of scientific evidence and standards of practice, including assessing peer-reviewed medical literature, pharmacoeconomic studies, outcomes research data, and other such information as it determines appropriate.”

Plans must have procedures in place that will allow a covered individual to request and gain access to clinically appropriate medications not covered by the plan.

The dollar amount of coverage that must be provided will vary according to the type of plan purchased. Copays and deductibles are still governed by the dollar limitations of the ACA.

Asking your doctor if a medication is right for you is just the first step. Asking if your plan thinks it’s right for you is another matter.


For further information, we invite you to download the following Legal Insights White Paper:

The Affordable Care Act: Mandated Benefits Compliance Standards

Further Reading and References:

Prescription Drug Benefits, 45 C.F.R. § 156.122
USP Medicare Model Guidelines v6.0 (Categories and Classes), available at http://www.usp.org/sites/default/files/usp_pdf/EN/healthcareProfessionals/uspmmg_v6_0_cat-class.pdf