California regulators proposed prescription drug protections for HMO members Tuesday, describing the rules as the nation's first to mandate broad coverage of medically necessary medications.
Although they hailed the thrust of the draft regulations, patient advocates said they feared vague language could allow health maintenance organizations to raise drug co-payments beyond the reach of many consumers, contradicting the spirit of the 2002 law the rules are supposed to implement.
HMO representatives said they were still assessing whether the proposed rules preserved the health plans' ability to charge more for higher-cost drugs when others would do as good a job.
The regulations are intended to ensure that HMOs cover drugs prescribed by doctors for medical conditions, said Cindy Ehnes, director-designate of the state Department of Managed Health Care, which drafted the proposed rules. They would allow health plans to make only a few categorical exclusions, such as cosmetic drugs and weight-loss medications for people who haven't been diagnosed as morbidly obese.
Describing herself as the mother of an asthmatic dependent on access to prescription drugs, Ehnes said she was pleased to help produce what could be a model of uniform standards to assist health plans in developing lists of covered drugs.
"With these new regulations there will be no doubt in a patient's mind as to which drugs are covered," Ehnes said, "and the vast majority of prescription drugs will be available to California HMO consumers."
For HMOs, a big issue is whether they'll be able to maintain tiered drug lists that translate into higher charges for more expensive drugs when equally effective generics and other cheaper medications are available.
"Once you determine that there are a handful of drugs with similar quality and efficacy, then we believe it's a health plan's role to pay attention to costs for purchasers and consumers," said Bobby Pena, a spokesman for the California Assn. of Health Plans, which represents HMOs. "As we are reviewing the regulations over the next week or so, we want to advocate not only for quality and efficacy but also for cost."
The regulations would require health plans to seek prior approval from the Department of Managed Health Care to limit access to particular drugs, as opposed to deciding coverage disputes case by case when patients complain, Ehnes said. Health plans also would be required to list all drug exclusions and limitations on their websites and in evidence-of-coverage handouts.
