The multibillion-dollar question for the pharma industry is what kind of prescription drug coverage will be offered under the state exchanges. For states with strong Medicaid MCOs, all signs point toward aligning benefits more with the state's Medicaid model than with Medicare or commercial benefits. The strongest rationale is that it would help with continuity of coverage for people dropping off Medicaid and going into an exchange plan or vice versa.

Certainly the approach Tennessee is taking in designing its exchange points toward the Medicaid model. To eliminate churn and make it easier for families, the state won approval of a Bridge option, a broader form of a Qualified Health Plan that will help bridge the gap for families who may have some members in Medicaid and others in the exchange.

In this model one family with some members who qualify for both Medicaid and the exchange would be covered under one health plan one family, one card-- for a period of time that would be determined. With federal approval, the state will now encourage Medicaid MCOs to expand product offerings in order to be able to cover a family whether members are eligible for the exchange or Medicaid.

To date, there is little guidance from the federal government on prescription benefits in the exchanges. In its Essential Health Benefits Bulletin (December 2011) the Center for Consumer Information and Insurance Oversight offered the one guiding principle that plans will offer at least one drug per category or class. States and health plans will likely lobby for having more than one drug per class so they can encourage competitive bidding with pharma and better negotiate pricing.

Basing pharmacy benefit design on commercial plans programs is another strong possibility in some states. To determine their essential health benefits, states can choose from four groups of benchmark plans, including one of the largest small-group plans in the state, one of the largest state employee health plans, one of the largest options available in the Federal Employees Health Benefits Program, or the largest HMO offered in the state's commercial market. These commercial plans vary widely in their pharmacy benefit design.

In essence, a state-by-state analysis of state exchange development and work group reports could assist the drug industry in knowing which way the state will turn to define drug benefits in its exchange. In these public reports and in states questions to CMS, there are hints of whether they are leaning toward following Medicaid, Medicare or certain benchmark plans in designing benefits.


DRG becomes Clarivate

View Now