On March 24, 2020, the Center for Consumer Information & Insurance Oversight, an agency within the Centers for Medicare & Medicaid Services (CMS), released a guidance document titled “FAQs on Prescription Drugs and the Coronavirus Disease 2019 (COVID-19) for Issuers Offering Health Insurance Coverage in the Individual and Small Group Markets.” This guidance document specifies that health plans can provide enrollees with medication refills beyond a 90-day supply, as nothing in federal regulations prohibits this. Accordingly, CMS urged health plans to authorize additional refills and waive restrictions on medication refill limits to help patients maintain a supply of their medications while many Americans are practicing social distancing and sheltering in place to avoid exposure to COVID-19. For some high-risk patients, repeated trips to the pharmacy to obtain monthly refills could invite disastrous health consequences.
The guidance document also includes information about how health plans should address prescription drug access issues, such as drug shortages recognized by the U.S. Food and Drug Administration. To maximize patient access to medically necessary treatments during a drug shortage, CMS recommends that health plans work with patients and their providers to cover a therapeutically-equivalent drug that may not be included on the plan’s formulary as a replacement for the drug experiencing a shortage. CMS also recommends that health plans waive prior authorization and step therapy requirements that would delay patient access to therapeutically-equivalent drugs that are included on the plan’s formulary when they are covered as a replacement for a drug experiencing a shortage. To reduce costs associated with therapeutically-equivalent drugs provided to enrollees, CMS recommends that health plans cover these drugs while applying cost-sharing requirements that are equal to or more generous than the drug that is experiencing a shortage. To improve the ability of patients to conveniently access their medications, CMS recommends that health plans allow enrollees to obtain their medications at out-of-network pharmacies as if they were obtained at an in-network pharmacy. This will allow patients to maintain access to their medications when they cannot reasonably obtain them from an in-network pharmacy.