Drug Exceptions Under the Affordable Care Act

As the Affordable Care Act provides more and more clarification on the law, we are starting to see some serious mandates outside of what was known.

If you are receiving health insurance coverage through an ACA-compliant plan, you may be eligible for additional drug coverage that is not currently covered by your plan. The law stats that this drug coverage exception must be made by the carrier. This opens up a path to getting a drug covered that was not previously covered. Before this, if the plan did not cover a drug, it was difficult to get that drug covered at all.

We at Nefouse & Associates were able to get exceptions made in the past by going through the carrier and showing medical necessity. Now it appears that you will still have to show medical necessity, but now there is a path under the ACA.

It’s difficult to know whether you can get an exemption for a formulary drug under the ACA.

Exception Criteria

1. Request for coverage of a drug that is not on the formulary list:For this exception, your medical provider would have to prove that all of the drugs on the formulary list are ineffective at treating your condition. There would have to be both clinical and scientific evidence that the condition could not be treated by the other covered medications, or that the other medications had adverse side effects.
2. Dose limit/quantity limit:It would have to be proved that the maximum allowed dose or frequency has been ineffective in treating the condition. There is going to be a lot of checks and balances with toxicity risks and lab measurements.
3. Step therapy for formulary drug:In this situation the plan would ask that you take a different drug first before approving the formulary drug. Your doctor would have to prove that the step therapy drug would cause an adverse reaction. Most common step therapy drugs are going to be antacids. I think the exception is more geared to cardiovascular drugs.
4. Brand exclusion/generic requirements:In today’s fully-insured health insurance market, we are seeing more and more generic requirements, even if the brand drug is of medical necessity. This aspect of the law may steer the carriers away from forcing members to take only generic drugs or pay the difference.

This is only a snapshot of the exception rules. It would be a very long drawn out process to get some drugs approved. Your doctor has to be willing to work on your behalf by submitting all information that will make you eligible for the exception. In some cases, they are not only going to have to submit medical records showing medical necessity, but make a strong argument on your behalf. There is a lot more information on applying for an exception.

The approval process can take up to 1 year to get approved. You still want to have Nefouse & Associates in your foxhole if you need to go to war with a carrier. Contact Nefouse & Associates, or call us at (800) 846-8615.