Health insurance exchange formularies: Charting new waters in the world of formulary
September 6, 2013
New regulations in the Patient Protection and Affordable Care Act have led to the birth of essential health benefits. The Centers for Medicare and Medicaid Services’ (CMS) new division, the Center for Consumer Information and Insurance Oversight (CCIIO), is responsible for the oversight of the insurance offerings on the new health insurance exchanges, which have 10 required essential health benefit categories. One of these essential categories is prescription drugs. Prospective qualified health plans, prescription benefit managers, and consultant agencies have struggled through the legislation and guidance from CCIIO in an attempt to build benefits that meet the requirements. With elements of typical commercial offerings as well as those of Medicare Part D, there are many nuances that one must consider when building an exchange formulary and creating the surrounding benefit.