13th March 15:54
HMOs must cover medically necessary drugs (weight)
Thanks to Gina for sending us the following article. . .Myrl
HMOs must cover medically necessary drugs
New state guidelines called first in nation
By Sarah Skidmore
UNION-TRIBUNE STAFF WRITER
January 6, 2005
California released regulations this week that require health
maintenance organizations to cover any medically necessary
prescriptions for members.
The California Department of Managed Health Care said the guidelines
are the first of their kind in the nation and will guarantee that
patients have access to the drugs they need.
"Patients need to feel confident that when their doctor prescribes a
necessary drug, their insurance will cover it at an affordable price,"
state Sen. Jackie Speier, D-San Francisco/San Mateo, said in a
statement. "Patient health is the bottom line."
Speier sponsored legislation in 2002 that required the department to
draft the regulations. The rules are open for public comment until Jan.
31, and the state will consider public input before making any
necessary changes and implementing them later this year.
Under the regulations, every HMO that offers outpatient prescription
drug benefits must provide all medically necessary prescription drugs.
This would exclude, in some instances, drugs without a specific medical
benefit such as those used for cosmetic purposes, weight loss or ***ual
performance. HMOs that want to exclude a drug must get the approval of
the Department of Managed Health Care.
Additionally, co-payments for the drugs cannot exceed 50 percent of the
price of the drug.
Still, consumer advocate Jerry Flanagan of the Foundation for Taxpayer
and Consumer Rights said the legislation went through with a good
"As is, the bottom line is access will be limited because consumers
will be paying more out of pocket," Flanagan said. "Many consumers
already cannot afford prescription drugs."
Bobby Pena, spokesman for the California Association of Health Plans,
said it's unclear how the rules will affect plans. He said his group is
still ****yzing the guidelines.
One area the group is looking at closely is how the rules will affect
use of generics, tiered pricing and, ultimately, savings on drugs, Pena
"There are a number of different drugs that do the same thing," he
said. "We believe as a health plan it's important . . . to advocate for
affordability as well.