Cohen Joshua P, Felix Abigail, Vasiadi Magdalini
Tufts Center for the Center of Drug Development, School of Medicine, 75 Kneeland St, Boston, MA 02111. E-mail:
Am J Manag Care. 2014 Feb;20(2):153-8.
To examine health plan compliance with essential drug benefit regulations in California and Massachusetts and at the federal level.
Health plan formulary review and analysis.
We analyzed formularies from the 3 largest small group plans in California and Massachusetts, including each state's benchmark plan. With respect to both federal and state regulations, for each health plan, we examined whether the drug was covered, the designated patient cost sharing tier of the drug, and which conditions of reimbursement were applied to the drug.
Most drugs included in state and federal mandates are covered by both benchmark and non-benchmark plans. However, health plans are not fully compliant with state and federal regulations. Significant differences among plans relate more to cost sharing and conditions of reimbursement, such as prior authorization, step edits, and quantity limits, than to drug coverage. CONCLUSIONS/POLICY IMPLICATIONS: Because health plans in California and Massachusetts are not fully compliant with state and federal mandates, they will have to adjust their formularies to meet minimum requirements. State policy makers need to balance competing aims of comprehensiveness of coverage and drug affordability. They must consider: (1) choice of benchmark plan -choice of a more generous benchmark plan implies less leverage for negotiating lower prices; and (2) breadth of state mandates which, if they exceed federal mandates, must be paid for by the states.
研究加利福尼亚州、马萨诸塞州以及联邦层面的医保计划对基本药物福利法规的遵守情况。
医保计划处方集审查与分析。
我们分析了加利福尼亚州和马萨诸塞州最大的3个小团体医保计划的处方集，包括每个州的基准计划。对于联邦和州法规，针对每个医保计划，我们审查了药物是否被涵盖、药物指定的患者费用分摊等级，以及哪些报销条件适用于该药物。
州和联邦规定中包含的大多数药物都被基准计划和非基准计划所涵盖。然而，医保计划并未完全遵守州和联邦法规。计划之间的显著差异更多地与费用分摊和报销条件有关，如预先授权、逐步调整和数量限制，而非药物覆盖范围。结论/政策启示：由于加利福尼亚州和马萨诸塞州的医保计划未完全遵守州和联邦规定，它们将不得不调整其处方集以满足最低要求。州政策制定者需要在覆盖范围的全面性和药物可负担性这两个相互竞争的目标之间取得平衡。他们必须考虑：（1）基准计划的选择——选择更慷慨的基准计划意味着在谈判降低价格方面的影响力较小；（2）州规定的广度，如果州规定超过联邦规定，则必须由各州承担费用。
