Patients undergoing treatment with nonformulary drugs will soon get a speedier decision from their health plans about whether those drugs can be covered.
On May 16, the Health & Human Services (HHS) department released a final rule outlining standards for health plans participating in the Affordable Care Act’s insurance exchanges in 2015. The rule creates an expedited process for determining coverage for nonformulary drugs in emergency situations.
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Next year, health plans in the ACA exchanges will have 24 hours to make a decision on whether to cover a nonformulary drug when it is requested.
In 2015, health plans in the ACA exchanges will have no more than 24 hours to make a decision on whether to cover a nonformulary drug when it is requested under "exigent circumstances." These situations include when a patient’s diagnosis may seriously jeopardize their life, health, or ability to regain maximum function. It also includes situations in which a patient is undergoing a current course of treatment using a nonformulary drug, according to the final rule.
Under the rule, patients or their designees – including prescribing physicians – can request coverage of a nonformulary drug.
HHS said the 24-hour review period begins as soon as a request is received, and cautioned insurers not to hold up the review if "largely procedural" information is missing from the request. The agency also instructed health plans not to require "irrelevant or overly burdensome information" in the application.
If a request for a nonformulary drug is approved, health plans must make it available for the duration of the emergency situation.
mschneider@frontlinemedcom.com
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