Health Care Coverage – Don’t Leave Home Without It

By David Root, Vice President of Government Affairs at Prime Therapeutics

June 21, 2023

Summer is here, which means travel season is in full swing for millions of Americans. And while people have their pre-trip routine down to hold their mail or notify their bank or credit card company before they leave, few people think to notify their health insurer or pharmacy benefit manager (PBM). But with recent legislative action in some states impacting how health plans operate and what treatments may or may not be covered, people’s travel could be anything but care-free.

The path to this point is complex, and while much of this legislative activity has been driven by a desire to make health care and prescription drugs cheaper for consumers, the results have created greater complexity and added potential costs. Some states have enacted laws that impact how health plans and PBMs operate state-by-state, including the elimination of mail order pharmacy networks. Other actions have impacted how employers and their PBM partners design health plans, eliminating or putting restrictions around coverage, most notably reproductive and gender-affirming care.

This activity has led to a concept of extra-territoriality where states are not only focused on insurers and how they administer care in their state, but also the impact of how out-of-state payers can manage plans in other states. And the ramifications are substantial.

For example, as more employers have let employees work remotely, even in midsize industries, this state-specific level of plan design means employers can’t construct a unified benefit. This also leads to issues of fairness and equity because now two people at the same company with the same job may not have the same access to care because they live in different states. In the end, this all could lead to increased health care costs or even legal action. And while the full impact of this may not be felt for some time, it’s clear that extra-territoriality could lead to a host of unintended consequences; at the top of that list is added waste in our health care system.

It’s daunting, but consumers and health plans have tools at their disposal – education and advocacy. For starters, consumers should be aware of their health plan benefits and what may or may not be covered. And if traveling out-of-state, consumers should contact their health plan administrator to find out if the care they may need when traveling is covered where they are visiting.

For health plan administrators, the Prime Therapeutics team – in conjunction with industry advocates like Pharmaceutical Care Management Association – are working on your behalf.

The industry can do better to educate stakeholders on the ways PBMs make the health care system operate better, but we also are focused on standing up for consumers and health plan administrators.

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