Paying For Essentials: Fight Brewing Over Specialty Tiers In Exchange Plans
Biopharmaceutical companies, patient groups and other stakeholders are pushing for federal guidelines specifically barring the use of formulary specialty tiers in private health insurance plans for individuals and small groups.
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Released Dec. 16, the HHS bulletin previews the regulatory approach the department plans to propose to define covered services under the EHB standard, which must be followed by plans participating in state-based insurance exchanges that will start operating in 2014 under the Affordable Care Act.
BIO advises HHS officials in an Oct. 25 "listening session" that the essential health benefits regulations for private insurance plans should incorporate a number of Medicare Part D formulary policies - except the one that allows use of specialty tiers.
Legislation is pending in a number of states that would ban or set limits around the use of formulary specialty tiers in private insurance. However, most of the bills appear to be on hold pending implementation over the next six to eight months of new insurance requirements under the health reform law.