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Essential Benefits PPACA - Limit on Specialty Drugs


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Guest in-house benefits

We have a self funded health care plan. We currently have a 25k limit on specialty drugs. We understand that we can't have an annual limit of 25 k for drugs such as MS drugs but there is currently a REALLY expensive psoriasis drug out there. Can we have a 25k limit on a specialty drug which doesn't appear to be prescribed for "essential care ." Our drug benefit manager rep says yes but I believe his in-house attorney thinks no. Is it a "reasonable" interpretation of essential benefits (which as you all know has prescription drugs as a general category) to put a 25k limit on a prescription drug which treats a seemingly non essential benefit? AHHH Any help? Any other way to do some serious cost sharing for this drug?

Thanks

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Unfortunately I think the answer is to lift the limit. Sec. 1302(b) says that the Secretary shall define the essential benefits, "except that such benefits shall include at least the following general categories and the items and services covered within the categories . . . ." Prescription drugs is listed as a category, and so I think the question is whether you can take the good faith position that psoriasis does not fall into that category. I do not think you can do that, and so I agree with the attorney. You could add other limits--such as a dosage limit as long as there was no limit on the amount of money you spent per dosage. And if you didn't care about grandfathered plan status, you could simply eliminate the benefit.

I know this is a stupid result, but hopefully the agencies will come out with more favorable guidance.

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