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When a drug is approved Plans may not charge a higher Not addressed.
through an exception process, co-pay for drugs approved on
the co-pay should be no higher exception than the highest co-
than the co-pay of the plan’s pay level for formulary drugs.
preferred drug. But this may be more than the
co-pay applicable to the plan’s
preferred drug.
Written materials given to new Not addressed. Although a plan says drugs are Not addressed.
and prospective members “covered” and non-formulary
should clearly delineate what drugs are not specifically
is a “covered benefit” and excluded, they may deny
what is “excluded.” coverage on the basis that
specific non-formulary drugs
are not covered.
Drugs covered at the time an Plans can make unilateral Insurers may delete drugs
insurance policy is purchased changes in the formulary or to from the formulary with 30
should not be deleted from PBMPs any time during a days notice. Any other
the formulary unilaterally by contract year. However, NAIC changes do not require notice.
the insurer until the policy does require plans to give 60
period is over and the days notice to members.
consumer has the option to
switch to another carrier.
New drugs should be No specific language, just a Not addressed.
promptly considered by the requirement that the P&T
P&T committee for coverage. committee meet at least
annually to update the
formulary.
The P&T committee should P&T Committees must meet at An earlier draft did require P&T Committees must meet at
meet at least quarterly to least annually. quarterly meetings, but was least annually.
consider the need to modify cut.
its formulary or their PBMP
policies as applied to specific
drugs based on new
information and studies.
The P&T committee should Not addressed. Not addressed.
consider requests for changes
to their formulary or PBMPs
from both practicing
physicians and consumers
affected by their decisions.
Desired Provision NAIC Provision Comment Insurance Industry
Alternative
P&T committees should include P&T committee should include Actively practicing P&T committee should include
licensed, actively practicing clinicians with “knowledge & practitioners have a better clinicians with “knowledge &
physicians and pharmacists. expertise” about drugs. awareness of current day expertise” about drugs.
hassles and patient needs
than corporate employees,
even though they may have
been trained as MDs or
pharmacists.
Therapeutic interchange Therapeutic interchange is not Therapeutic interchange is not
should only be allowed with recognized as a PBMP and recognized as a PBMP and
case-by-case approval from therefore is not addressed. therefore is not addressed.
the prescribing physician.
Health plans should not NAIC allows plans to Not addressed.
establish arbitrary limits on specifically and explicitly
the quantity of a specific exclude or restrict coverage or
medication it will cover. Such number of doses in the terms
restrictions should only be of coverage.
based on clinical evidence.