Prime is in compliance with ACA contraceptive coverage guidance
April 7, 2023
Prime was recently contacted by a Fortune magazine reporter who is writing a feature investigation, publishing later this month, about the business of contraceptive therapies. The article is focusing on how alleged payer noncompliance with the Affordable Care Act’s contraceptive coverage mandate is creating financial difficulties for small pharmaceutical companies that have tried to innovate in this market.
The article will be specifically naming Prime Therapeutics and Blue Cross Blue Shield as two of the payers who were characterized as noncompliant in the U.S. House Oversight Committee’s October 2022 report. The reporter has also spoken to pharmaceutical company executives, patients, providers and nonprofit experts. We anticipate this article to be negative with respective to Prime and other payers.
In November, you may have seen communication from Prime following the release of the Oversight Committee report, including the key findings/Prime position document. We stand by our findings that we are in full compliance with ACA guidance related to contraceptive coverage.
We provided the reporter with the following statement, authored by David Lassen, PharmD, Prime’s Chief Clinical Officer:
Prime Therapeutics (Prime), as a pharmacy benefits manager (PBM), manages pharmacy benefits at the direction of its clients. Prime strives to meet all legal and regulatory obligations including those related to contraceptive coverage. As a PBM, Prime does not dictate coverage determinations of contraceptives or any other drug. Rather, Prime provides comprehensive support to its clients to facilitate the coverage of safe and efficacious drugs in a cost-efficient manner. At times, this strategy includes preferring the generic alternative of a brand name drug, a common and often cost-saving medical management approach in the PBM industry. In some situations, contraceptive products are covered under the client’s medical benefit, rather than the pharmacy benefit, in which case Prime as a PBM does not adjudicate coverage determinations. Prime strives to follow all updated compliance requirements, and we work with our health plan clients to adjust our processes and coverage recommendations accordingly.
All decisions regarding the therapeutic role of these products go through an extensive clinical evaluation process through our National Pharmacy and Therapeutics (P&T) Committee which is comprised of actively practicing specialists that approve our clinical position for these therapies based on efficacy, safety and uniqueness (not cost).
Please reach out to your Prime client engagement representative if you have further questions.