PBIRx's Role in Healthcare Reform Compliance

PBIRx®

Intelligent Solutions in Pharmacy Benefits

612 Wheelers Farms Road, Milford, CT 06461

(888) 797-2479

The topic of Healthcare Reform, otherwise known as The Patient Protection and Affordable Care Act (PPACA), the Affordable Care Act (ACA) or even "Obamacare," is one that requires a lot of attention in the pharmacy and pharmacy benefit industry. Being that the first version of the law reads "The Patient Protection and Affordable Care Act," one may assume that this law has adjusted healthcare plans to be more affordable today than in the past. However, the nature of the law suggests that the desired level of affordability is still not where many hoped it would be.

A particular section of the Affordable Care Act that we would like to point out is Coverage of Preventive Services. There are specific terms and guidelines stated by the US Preventative Services Task Force (USPSTF), as to what preventive services must be covered under a patient's health plan and some of those services also include the coverage of certain pharmaceutical drugs at a zero copayment.

This is where PBIRx steps in! At PBIRx, one of our responsibilities related to the Affordable Care Act is to make sure that all of our clients are compliant with the USPSTF coverage of certain drugs for plans that are non-grandfathered. Thus, we carefully review our clients' current plan design of covered drugs and make sure that they accurately reflect the guidelines stated in the ACA and that such guidelines have been implemented appropriately with their PBM and communicated to our clients' members. But our services don't stop there! As we work towards making sure everyone is compliant with the law, we also make sure our clients have the necessary documentation such as a Summary of Benefits and Coverage available to their members.

The following is a list of preventative drugs often subject to certain criteria, which may include age and/or disease state, for which the USPSTF mandates a zero copay:

• Aspirin to prevent cardiovascular disease for certain ages
• Fluoride Supplements
• Folic Acid
• Iron Supplements
• Vitamin D
• Immunizations
• Oral Contraceptives
• Breast Cancer Preventive (plan renewals starting 10/1/14)
• Aspirin for preeclampsia risk (plan renewals starting 9/1/15)

Furthermore, it is important to note that smoking cessation coverage is also included in the list of preventative drugs that the USPSTF mandates a zero copay for. However, since this coverage does not have a deadline, anyone that currently requests drugs or services to aid in this process at a $0 copay is given a "safe harbor" compliance status.

For more information on how PBIRx works to help with ACA compliance, please give us a call at (888) 797-2479 today!