No, Obamacare Won’t Cover Every Drug — Just Like Every Other Insurance Policy

[sinkingfeeling]

http://thinkprogress.org/health/2013/12/10/3042741/drugs-obamacare-coverage/

The ACA requires that issuers provide the greater of one drug from each category or class, or offer as many drugs in each category as are covered by a benchmark plan. The law allows states the choice of four different benchmarks, which Gottlieb helpfully lists in his article: 1) One of the three largest small group plans in the state by enrollment; 2) one of the three largest state employee health plans by enrollment; 3) one of the three largest federal employee health plan options by enrollment; or 4) the largest HMO plan offered in the state’s commercial market by enrollment.

States — not the federal government — select the benchmark and insurers then offer coverage for the drugs listed in those formularies. “What the vast majority of states have chosen is a common small business plan, so you know it’s saying what will be available in the exchanges and in the individual market generally is what’s popular among small businesses now and that seems like a reasonable place to start,” the Kaiser Family Foundation’s Larry Levitt explained.

But yes, there are certain limits: a formulary, for instance, may cover three drugs for treating a certain condition but not two others. Obamacare — like all insurers currently operating in the market — has a fix for that. ACA regulations demand that a health plan must have an “exceptions process” in place that allows patients to request and gain access to clinically appropriate drugs that aren’t covered by the health plan (in addition to internal and external appeal processes). So, if a health plan does not cover a particular drug that a patient absolutely needs, their doctor can certify medical necessity to extend coverage. Insurers have relied on drug formularies before the law went into effect and already have exceptions processes in place, meaning that most “will not have to implement significant changes.”