When Covered California first opened for business in 2014, comparing qualified health plans by the drugs they cover was an exercise in frustration.
As outlined in my reform blog a year ago, the public insurance exchange site did not provide readily available formulary information. Some health plans posted the exchange formularies on their websites, but they were difficult to distinguish from other plan drug lists, and the lack of standardization made the lists difficult to navigate and compare.
As 2015 open enrollment season approaches, the Covered California site has greatly improved, directly linking to all 10 plans? formularies. But the formularies are each formatted differently, which may confuse consumers who are not used to looking at details such as tiering and prior authorization and step therapy controls.
That will change, thanks to a new law in California that will eventually require all plans in California to use a standard formulary. The catch: It won?t happen for at least three more years. The new law, based on Senate Bill 1052, requires the two insurance state regulators (the Department of Managed Health Care and Insurance Department) to devise a standard formulary by Jan. 1, 2017. Within six months after the template is developed, all insurance plans in California, not just those on the exchange, will have to conform to that template and post regular formulary updates.
More immediately, by Jan. 1, 2015, the law requires qualified health plans in the Covered California exchange to post their formularies on their websites and the exchange to link to them. Currently, insurers are only mandated to file their formularies with the regulatory agencies.
Senate Bill 1052 was sponsored by the American Cancer Society Cancer Action Network, which contended that obtaining information to confirm drug coverage was ?impossible or incredibly time consuming,? according to a Senate analysis of the bill.
Initially, Sen. Norma Torres, D-Pomona, author of the bill, sought to standardize the formulary process through a search-enabled portal on the Covered California website, enabling site visitors to search for their drug and view its coverage on various plan formularies. Among the experts, the Senate staff consulted representatives from Decision Resources Group to gain knowledge from Fingertip Formulary, DRG's searchable database of drug coverage nationwide. Although the searchable model was deemed too expensive for the state to develop under the auspices of SB 1052, Erric Garris, policy director for Torres, said he hopes to revive the concept in a new bill next year.
Health plans opposed the legislation, particularly the standardization piece. One of their arguments is that plans should be able to retain the flexibility to present their drug lists and benefit designs as they see fit, in part to distinguish themselves from their competitors. But this is really about California consumers, particularly those with debilitating diseases for whom drug coverage makes a big difference in choice of health insurance plans. With all the benefit decisions facing them, including confusion over narrow provider networks, why not make it as easy as possible to determine not only how much they will pay for drugs, but whether their drugs are covered at all?
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