By Lauren Flynn Kelly - February 2, 2012

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The comment period for responses to HHS’s Dec. 16 bulletin on essential health benefits packages has just closed, and a variety of stakeholders have expressed concerns over the agency’s intent to give states “flexibility” in choosing an existing health plan to define the benefits that must be included in individual and small-group plans in 2014. Four types of insurance plans were offered as potential “benchmark” plans.

Of special interest to Drug Benefit News, of course, is how prescription drug coverage will be defined under this piece of health care reform. The elusive document named prescription drugs as one of 10 required coverage categories and devoted one paragraph to pharmacy benefits, stating its intent to “propose a standard that reflects the flexibility permitted in Medicare Part D in which plans must cover the categories and classes set forth in the benchmark,” with a footnote saying it does not intend to adopt the protected drug class policy in Part D, referring to CMS’s designation of six drug classes in which “all or substantially all drugs” must be included on formularies.

That footnote was music to PBMs’ ears, as protected drug classes would arguably diminish plans’ ability to negotiate discounts from manufacturers, and was mentioned in letters from both the Academy of Managed Care Pharmacy and the Essential Health Benefits Coalition, which includes Express Scripts, Inc., Prime Therapeutics LLC and the Pharmaceutical Care Management Association as members. As CEO Edith Rosato wrote in the AMCP letter to HHS, “This coverage requirement has made it difficult, if not impossible, for plan sponsors to negotiate favorable rates for the drugs in these classes, as pharmaceutical manufacturers know that the plans are required to cover their products regardless of cost.”

Moreover, the bulletin stated, “If a benchmark plan offers a drug in a certain category or class, all plans must offer at least one drug in the same category or class.” This is commonly referred to as the “one-drug per-class” requirement, which prompted Avalere Health LLC to perform an analysis of how formulary coverage varies among potential benchmark plans. Among the results of that analysis is that formularies offered by several “proxy” plans had much more to offer than just “one-drug per-class.”

What challenges do you foresee for the inclusion of drug benefits under EHB packages?