Proposed Changes to Rx Information Required in SBC, Greg Judd, CEBS
The American Medical Association (AMA) and the Pharmaceutical Research and Manufacturers of America (PhRMA) are asking regulators to build more information about major medical plan drug coverage into the next revision of the Summary of Benefits and Coverage (SBC) and the Uniform Glossary (LifeHealthPro).
1. The AMA wants SBCs to state whether the plan’s out-of-pocket cost limit includes a patient’s prescription drug costs.
2. The AMA says the SBC prescription drug information link should go to a website that lets consumers search for specific drugs in the formulary associated with the plan described by the SBC.
3. PhRMA reps would like regulators to change the proposed definition of “specialty drug.”
The current draft version calls for regulators to define a “specialty drug” as “a type of prescription drug that, in general, requires special handling or ongoing monitoring and assessment by a health care professional, or is relatively difficult to dispense.”
“If the plan’s formulary uses ‘tiers,’ and specialty drugs are included as a separate tier, you will likely pay more in cost sharing for drugs in the specialty drug tier,” according to the draft.
The PhRMA reps say that definition is unclear, and they suggest that the glossary should use the term “specialty category,” rather than “specialty drug.”
The PhRMA reps proposed the following rewrite: A formulary category, or “tier,” sometimes used to separately group prescription drugs that, in general, require special handling or ongoing monitoring and assessment by a health care professional. If the plan‘s formulary uses categories, and certain drugs are placed in a specialty category, you will likely pay more out of pocket for drugs in that category.
We believe that PhRMA’s definition actually opens the way to getting everyone to think about specialty as bridging medical & Rx, so that’s probably a good thing. CMS is already on board with #2