1. Pink Sheet

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...

Read the full article – start your free trial today!

Join thousands of industry professionals who rely on Pink Sheet for daily insights

  • Start your 7-day free trial
  • Explore trusted news, analysis, and insights
  • Access comprehensive global coverage
  • Enjoy instant access – no credit card required
Start Free Trial

Already a subscriber?

More from Market Access

More from Pink Sheet

FDA’s FY 2026 Budget Request Lacks New Policy Proposals

 
• By Sue Sutter

The White House requested $6.8bn for the FDA, down 3.9% from the current funding level, but does not propose any legislative changes. In previous years, the agency used the budget process to seek statutory fixes specific to generic drugs and shortages.

User Fee-Funded Staff Would Drop In FY 2026 US FDA Budget

 
• By Derrick Gingery

The reductions across medical product programs in the agency’s budget request include hundreds of positions funded by user fees, which may foreshadow its upcoming user fee restructuring strategy.

Canada Cuts Red Tape With Single Ethics Review For Trials

 
• By Neena Brizmohun

A new research ethics review system for multi-site clinical trials in Canada is expected to help improve study start-up times, avoid unnecessary duplication and boost the country’s competitiveness on a global stage.