"The final regulation on all this, issued by the Department of Health and Human Services, gave states some latitude to nix drugs that might otherwise be listed on the benchmark formularies they selected. That regulatory wiggle room seems to undermine the whole idea of having a benchmark plan."
12/9/13, "No, You Can't Keep Your Drugs Either Under Obamacare," Forbes, Scott Gottlieb, MD
"Obamacare is a throwback to the old HMO model of the 1990s, which
promised a broad package of coverage for primary care benefits like
vaccines, and routine doctor visits. But to pay for these benefits, the
Obamacare plans skimp on other things – principally the number of
doctors you’ll have access to, and also, the number of costlier branded
drugs that make it onto formularies.
Many Americans rejected these restrictive HMO model plans in the
1990s, in favor of PPO-style plans that had higher cost sharing for
routine health services, but offered broader access to doctors and have
bigger drug formularies. What Obamacare says, in effect, is that
Americans made the wrong choice when they rejected those HMO plans in
favor of PPOs. The President thinks the more comprehensive, but
restrictive HMOs were the better choice after all.
In response to the drug formulary issues, and the potential for
important drugs to remain completely uncovered, staff at the Centers for
Medicare and Medicaid Services is arguing that patients will have the
option to appeal formulary decisions — to try and compel a health plan
to cover a given drug.
But this appeals process can take months. And there is no sure chance of winning.
If a drug costs tens of thousands of dollars a year, how many
patients will be able to foot that bill out of pocket until they win an
appeal. Or take the chance that they could lose the appeal, and be stuck
with the full cost of the drug?
The biggest problem in all of this is that consumers will have a very
hard time figuring out where they stand. In many cases, the health
plans being offered in the Obamacare exchanges don’t make information
about their drug formularies readily available. In some cases, it
doesn’t seem to be published anywhere.
The government was supposed to mandate that plans made this
information easily accessible. But in many cases, that never happened.
In fact, state and federal regulators must have approved the health
plans without reviewing final drug formularies. Many plans are also not
publishing information about their networks of doctors, or when they do;
the information is unreliable (listing, for example, doctors who argue
that they aren’t part of the plans)....
The formulary you’ll get depends most of all on which state you live
in (and which benchmark was chosen by the state regulators).
It also appears that the final regulation on all this,
issued by the Department of Health and Human Services, gave states some
latitude to nix drugs that might otherwise be listed on the benchmark
formularies they selected. That regulatory wiggle room seems to
undermine the whole idea of having a benchmark plan.
So can you find a good drug plan in Obamacare? It’s difficult.
Generally speaking, the benchmark plans that are part of the Federal
Employees Health Benefits Program have the best drug formularies, some
of the large HMOs, the worst. In many cases, states benchmarked their
Obamacare plans to state employee health programs, which usually fall in
But there is a lot of variability....
In California, a state that Obamacare’s architects are holding up as
the model of success, some of the major exchange players—including
Anthem, Blue Shield of California and Health Net—have posted their
exchange formularies on their websites. Unfortunately, they’re not easy
to find — and incomplete.
As another excellent analysis finds, a lack of standardization and on-line tools makes it hard for consumers to compare between plans.
Some of the published lists do not show all of the covered drugs. For
instance in California, Blue Shield’s document states that only the
most commonly prescribed drugs are shown in its published formulary.
Anthem’s published list is also not comprehensive....
Even if your drug makes it onto the Obamcare plan’s formulary,
getting access to a medicine can still be a costly affair for patients.
In the same study, researchers found that 90% of the lowest-cost
bronze plans require patients to pay 40% (on average) for drugs in tiers
3 and 4, compared with 29% co-pays in current commercial plans. Most of
the Obamacare silver plans also require patients to pay 40% for the
Drug makers with big portfolios of specialty and primary care drugs,
for their part, will have to fight on a state-by-state level to make
sure that the benchmark formularies that state regulators adopt allow
open access to their medicines.
There’s word that companies like Pfizer [NYSE:PFE] and Merck
[NYSE:MRK] have been beefing up their state operations for just this
purpose. They are late to the challenge....
The biggest challenge will be in getting
new drugs onto existing formularies. The process is likely to be long,
slow, and austere.
Health plans are cheapening their drug formularies – just like they
cheapened their networks of doctors. That’s how they’re paying for the
benefits that President Obama promised, everything from free
contraception and screening tests to a leveling of premiums between
older (and typically costlier) beneficiaries, and younger consumers.
But the need to fund these promises will put drug formularies in play
for the long run. New medicines will remain off formularies, or make it
on after long delays. Patients will find that costlier specialty drugs
are simply not covered.
Like a lot other parts of Obamacare, uncertainty around drug costs
and coverage is becoming another one of the scheme’s unpleasant
surprises." via Mark Levin twitter
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