AMCP urges HHS not to consider formulary changes when determining "grandfathered" status for health plans under reform law

The Academy of Managed Care Pharmacy (AMCP) has provided comments in response to a June 17 Federal Register notice on the Interim Final Rules for Group Health Plans and Health Insurance Coverage Relating to Status as a Grandfathered Health Plan Under the Patient Protection and Affordable Care Act (PPACA), also known as The Grandfathering Rule.

The PPACA, as modified by the Reconciliation Act and signed into law by President Obama in March, provides that certain group health plans and health insurance coverage existing as of March 23, 2010, are subject to only certain provisions of the Act. The statute refers to those plans and health insurance coverage as “grandfathered” health plans.

The Department of Health and Human Services (HHS) has determined that certain changes would cause a group health plan or health insurance coverage to cease to be a grandfathered health plan.

However, HHS has invited comments on whether other changes should result in the cessation of grandfathered health status for a plan or health insurance coverage. One of the changes in question includes “changes to a prescription drug formulary, and if so, what magnitude of changes would have to be made.”

AMCP strongly believes that the “dynamic and constantly evolving nature of a drug formulary” renders such a provision a non-compelling reason to discontinue grandfathered status, according to a letter dated Aug. 12 sent to HHS’ Office of Consumer Information and Insurance Oversight.

“Formulary changes must occur on a regular basis as FDA approves new medications and new uses for existing medications,” according to the letter. “P&T committees must consider formulary changes as new evidence becomes available on medications, which would change previous decisions on the effectiveness or safety of medications. Health plans and insurers must be able to make formulary changes to provide the most appropriate, cost-effective care to their members.”