AMCP Urges HHS to Allow Flexibility in the Design of Prescription Drug Benefits Under Health Care Reform Law

Managed Care Pharmacy Practices Ensure Quality Patient Care and Affordability

ALEXANDRIA, Va., Nov. 10, 2011  /PRNewswire-USNewswire/ -- The Academy of Managed Care Pharmacy (AMCP) is urging the Department of Health and Human Services (HHS) to allow health plans flexibility in designing the prescription drug benefit that will be required under the new health care reform law.

Based on the 2010 Affordable Care Act, an estimated 30 million individuals by 2016 are expected to obtain health insurance from private health plans participating in state insurance exchanges, as well as through state expansion of Medicaid programs.

These plans will contain a federally-determined "essential health benefits package," which includes prescription drugs.

In a recent letter to HHS, the Academy said it applauds the classification of a prescription drug benefit as one the essential benefits. At the same time, AMCP encourages HHS to include not only access to medications, but the management of medication therapies under this benefit. In addition, AMCP proposes that health plans maintain autonomy over the design of the drug benefit and the determination of which drugs are to be covered and deemed essential.

"Regulators should not define or require specific drugs or drug categories for inclusion or exclusion under the essential health benefits provision," AMCP argues. "Instead, health plans should be allowed flexibility in determining appropriate coverage."

"Flexibility in making prescription drug coverage decisions, and in designing the overall pharmacy benefit, will allow health plans to incorporate a range of best practices that have shown to improve clinical outcomes and control costs," says Edith A. Rosato, R.Ph., IOM, AMCP's new Chief Executive Officer.  

"Access to medications, along with their proper management, can reduce morbidity and mortality associated with many common diseases and conditions," she adds.

Management of drugs may include such practices as formulary management, medication therapy management, drug utilization reviews, tiered copayments or co-insurance, adherence programs, health information technology, and access to risk evaluation and minimization strategies management. AMCP's letter to HHS includes descriptions of these and other common managed care pharmacy practices.

Formularies are a particularly important tool in maintaining a pharmacy benefit. Medications and related products listed on a formulary are determined by a pharmacy and therapeutics (P&T) committee, or an equivalent entity.

"Due to the multiplicity of medications on the market, the continuous introduction of new medications, and the discovery of clinical misadventures once a product has been in use, a formulary must be a dynamic and continually revised listing," AMCP says.

P&T committees regularly make formulary changes as the Food and Drug Administration approves new medications and new uses for existing medications. These committees also make formulary changes as new evidence becomes available on existing medications that change previous decisions on the effectiveness or safety of medications.

"The flexibility to make formulary decisions and apply time-tested pharmacy management tools at the health plan level is crucial for ensuring the high quality and affordability of the prescription drug benefit," says Rosato.

AMCP encourages HHS to use this framework in defining a prescription drug benefit to be offered through qualified health plans and state expansion of Medicaid programs.

To read AMCP's comment letter to HHS, click here.

About AMCP
The Academy of Managed Care Pharmacy (AMCP) is a national professional association of pharmacists and other health care practitioners who serve society by the application of sound medication management principles and strategies to improve health care for all. The Academy's nearly 6,000 members develop and provide a diversified range of clinical, educational and business management services and strategies on behalf of the more than 200 million Americans covered by a managed care pharmacy benefit. More news and information about AMCP can be obtained on its website, at www.amcp.org. 

SOURCE Academy of Managed Care Pharmacy