Universal health care in america:: can the massachusetts model work nationwide?

MANDATING PRESCRIPTION DRUG COVERAGE Massachusetts was the first state to establish standards that apply to every resident, and it is the first to require that adults older than 18 years of age have a plan that mandates drug coverage.8 The minimum standards allow plans to charge an additional deductible for drugs of up to $250 for an individual. Many in the state’s health care community, including employer groups and insurance companies, oppose the drug mandate, calling it a burden for those who already cannot afford to add prescription benefits to their coverage.9 (Currently, approximately 160,000 people in Massachusetts have either a no-drug plan or a plan with less than the required drug coverage under the state’s new law.7) In addition, there is the concern that prescription benefits, although mandatory, will still be a difficult sell to those young, healthy patients who might not think that they need to add drug coverage to their plan.8 With the January deadline looming, the state has been looking for ways to keep premium prices under control without compromising access to most prescription drugs. The Connector staff was charged with developing a feasible strategy to accomplish this and has been working with the program’s participating insurance carriers to design more affordable plans.10 Their recommendations include the use of increased member cost sharing and a more limited, therapeutically based formulary, as well as other cost-containment approaches such as step therapy, prior authorization, quantity limits, and mandatory mail order for maintenance medications.10 Health New England (HNE), a local carrier in Western Massachusetts that has been participating in the Connector program since its inception, currently offers a Silver plan option with a generic-based formulary. The “Performance Formulary” has a two-tier structure. Tier 1 includes all generic drugs, and Tier 2 includes a limited number of brand-name drugs carefully selected based on clinical efficacy and cost efficiency. At least one medication is available to treat each disease state. According to HNE Medical Director Thomas Ebert, MD, the Performance Formulary was developed in response to the state’s new prescription drug mandate. “It was a burden from a cost perspective,” he said of the mandate. “But it was an opportunity that allowed us to experiment with a robust pharmacy benefit with restrictions.” The author is a medical writer living near Philadelphia, Pennsylvania.