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Prescription Coverage FAQ
Frequently Asked Questions
Where can carriers view the benchmark prescription drug formulary?
If the benchmark has "Zero" as the total number of drugs under that class, is the plan supposed to add one or is zero ok, since that is the benchmark?
Each EHB-compliant plan must offer the greater of a) one drug in every category and class; or b) the same number of drugs in each category and class of the EHB benchmark plan. Accordingly, if the benchmark plan does not offer a drug in a category or class, carriers must add at least one drug in that category and class.
Is there a list of rules for the formulary creations? Can drugs be on the plan's formulary lists that require prior authorization? Can you add quantity limitations (QL), age edits on drugs listed on the plan's formulary?
Federal guidance on prescription drug coverage under a QHP is found at 45 CFR 156.122. Under that section, an issuer providing EHBs to cover at least the greater of (1) one drug in every United States Pharmacopeia Convention (USP) category and class or (2) the same number of prescription drugs in each category and class as the EHB state benchmark plan. Prior authorization of prescription drugs is permitted as is step therapy. If a recommendation or guideline does not specify the frequency, method, treatment, or setting for the provision of that service, the issuer can use reasonable medical management techniques to determine any coverage limitations.