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Are Specialty Drugs ‘Non-Essential?’ The Argument Underlying Alternative Funding Programs

 
• By Sarah Karlin-Smith

Gaps and disputes around what the Affordable Care Act designates as ‘essential’ prescription drugs have allowed plans to provide more limited coverage of specialty medicines, some patient advocacy groups say. 

image of tree focused on intricate roots
Health plans contention that specialty drugs aren't an essential health benefit is a root issue underlying new insurance designs. • Source: Shutterstock

The existence of relatively new health plan driven strategies to shift more drug costs to patients rests in large part on a core dispute – when are prescription drugs treated as “essential” by the Affordable Care Act’s essential health benefits requirements.

Alternative funding programs (AFPs), whereby health plans usually carve out or other times automatically deny prior authorization for certain specialty drugs were designed in large part because health plans argue...

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