§ 156.122 Prescription drug benefits. ( a ) A health plan does not provide essential health benefits unless it: ( 1 ) Subject to the exception in paragraph (b) of this section, covers at least the greater of: ( i ) One drug in every United States Pharmacopeia (USP) category and class; or
( ii ) The same number of prescription drugs in each category and class as the EHB-benchmark plan;
( 2 ) Submits its formulary drug list to the Exchange, the State or OPM; and
( 3 ) For plans years beginning on or after January 1, 2017, uses a pharmacy and therapeutics (P&T) committee that meets the following standards. ( i ) *Membership standards.* The P&T committee must: ( A ) Have members that represent a sufficient number of clinical specialties to adequately meet the needs of enrollees.
( B ) Consist of a majority of individuals who are practicing physicians, practicing pharmacists and other practicing health care professionals who are licensed to prescribe drugs.
( C ) Prohibit any member with a conflict of interest with respect to the issuer or a pharmaceutical manufacturer from voting on any matters for which the conflict exists.
( D ) Require at least 20 percent of its membership to have no conflict of interest with respect to the issuer and any pharmaceutical manufacturer.
( E ) For plan years beginning on or after January 1, 2026, include at minimum one patient representative who must: ( 1 ) Represent the patient perspective as a member of the P&T committee.
( 2 ) Have relevant experience or participation in patient or community-based organizations.
( 3 ) Be able to demonstrate the ability to integrate data interpretations with practical patient considerations.
( 4 ) Have no fiduciary obligation to a health facility or other health agency and have no material financial interest in the rendering of health services.
( 5 ) Have a broad understanding of one or more conditions or diseases, associated treatment options, and research.
( 6 ) Disclose financial interests on their conflict-of-interest statements. Disclosed financial interests must include all interests with any entity that would benefit from decisions regarding plan formularies as well as specific information about their financial interests, such as the nature of the relationship and the value of the financial interest.
( ii ) *Meeting standards.* The P&T committee must: ( A ) Meet at least quarterly.
( B ) Maintain written documentation of the rationale for all decisions regarding formulary drug list development or revision.
( iii ) *Formulary drug list establishment and management.* The P&T committee must: ( A ) Develop and document procedures to ensure appropriate drug review and inclusion.
( B ) Base clinical decisions on the strength of scientific evidence and standards of practice, including assessing peer-reviewed medical literature, pharmacoeconomic studies, outcomes research data, and other such information as it determines appropriate.
( C ) Consider the therapeutic advantages of drugs in terms of safety and efficacy when selecting formulary drugs.
( D ) Review policies that guide exceptions and other utilization management processes, including drug utilization review, quantity limits, and therapeutic interchange.
( E ) Evaluate and analyze treatment protocols and procedures related to the plan's formulary at least annually.
( F ) Review and approve all clinical prior authorization criteria, step therapy protocols, and quantity limit restrictions applied to each covered drug.
( G ) Review new FDA-approved drugs and new uses for existing drugs.
( H ) Ensure the issuer's formulary drug list: ( 1 ) Covers a range of drugs across a broad distribution of therapeutic categories and classes and recommended drug treatment regimens that treat all disease states, and does not discourage enrollment by any group of enrollees; and
( 2 ) Provides appropriate access to drugs that are included in broadly accepted treatment guidelines and that are indicative of general best practices at the time.
( b ) A health plan does not fail to provide EHB prescription drug benefits solely because it does not offer drugs approved by the Food and Drug Administration as a service described in § 156.280(d) of this subchapter.
( c ) A health plan providing essential health benefits must have the following processes in place that allow an enrollee, the enrollee's designee, or the enrollee's prescribing physician (or other prescriber, as appropriate) to request and gain access to clinically appropriate drugs not otherwise covered by the health plan (a request for exception). In the event that an exception request is granted, the plan must treat the excepted drug(s) as an essential health benefit, including by counting any cost-sharing towards the plan's annual limitation on cost-sharing under § 156.130 and when calculating the plan's actuarial value under § 156.135. ( 1 ) *Standard exception request.* For plans years beginning on or after January 1, 2016: ( i ) A health plan must have a process for an enrollee, the enrollee's designee, or the enrollee's prescribing physician (or other prescriber) to request a standard review of a decision that a drug is not covered by the plan.
( ii ) A health plan must make its determination on a standard exception and notify the enrollee or the enrollee's designee and the prescribing physician (or other prescriber, as appropriate) of its coverage determination no later than 72 hours following receipt of the request.
( iii ) A health plan that grants a standard exception request must provide coverage of the non-formulary drug for the duration of the prescription, including refills.
( 2 ) *Expedited exception request.* ( i ) A health plan must have a process for an enrollee, the enrollee's designee, or the enrollee's prescribing physician (or other prescriber) to request an expedited review based on exigent circumstances.
( ii ) Exigent circumstances exist when an enrollee is suffering from a health condition that may seriously jeopardize the enrollee's life, health, or ability to regain maximum function or when an enrollee is undergoing a current course of treatment using a non-formulary drug.
( iii ) A health plan must make its coverage determination on an expedited review request based on exigent circumstances and notify the enrollee or the enrollee's designee and the prescribing physician (or other prescriber, as appropriate) of its coverage determination no later than 24 hours following receipt of the request.
( iv ) A health plan that grants an exception based on exigent circumstances must provide coverage of the non-formulary drug for the duration of the exigency.
( 3 ) *External exception request review.* For plans years beginning on or after January 1, 2016: ( i ) If the health plan denies a request for a standard exception under paragraph (c)(1) of this section or for an expedited exception under paragraph (c)(2) of this section, the health plan must have a process for the enrollee, the enrollee's designee, or the enrollee's prescribing physician (or other prescriber) to request that the original exception request and subsequent denial of such request be reviewed by an independent review organization.
( ii ) A health plan must make its determination on the external exception request and notify the enrollee or the enrollee's designee and the prescribing physician (or other prescriber, as appropriate) of its coverage determination no later than 72 hours following its receipt of the request, if the original request was a standard exception request under paragraph (c)(1) of this section, and no later than 24 hours following its receipt of the request, if the original request was an expedited exception request under paragraph (c)(2) of this section.
( iii ) If a health plan grants an external exception review of a standard exception request, the health plan must provide coverage of the non-formulary drug for the duration of the prescription. If a health plan grants an external exception review of an expedited exception request, the health plan must provide coverage of the non-formulary drug for the duration of the exigency.
( 4 ) *Application of coverage appeals laws.* ( i ) A State may determine that a health plan in the State satisfies the requirements of this paragraph (c) if the health plan has a process to allow an enrollee to request and gain access to clinically appropriate drugs not otherwise covered by the health plan that is compliant with the State's applicable coverage appeals laws and regulations that are at least as stringent as the requirements of this paragraph (c) and include: ( A ) An internal review;
( B ) An external review;
( C ) The ability to expedite the reviews; and
( D ) Timeframes that are the same or shorter than the timeframes under paragraphs (c)(1)(ii), (c)(2)(iii), and (c)(3)(ii) of this section.
( ii ) [Reserved]
( d ) ( 1 ) For plan years beginning on or after January 1, 2016, a health plan must publish an up-to-date, accurate, and complete list of all covered drugs on its formulary drug list, including any tiering structure that it has adopted and any restrictions on the manner in which a drug can be obtained, in a manner that is easily accessible to plan enrollees, prospective enrollees, the State, the Exchange, HHS, the U.S. Office of Personnel Management, and the general public. A formulary drug list is easily accessible when: ( i ) It can be viewed on the plan's public Web site through a clearly identifiable link or tab without requiring an individual to create or access an account or enter a policy number; and
( ii ) If an issuer offers more than one plan, when an individual can easily discern which formulary drug list applies to which plan.
( 2 ) A QHP in the Federally-facilitated Exchange must make available the information described in paragraph (d)(1) of this section on its Web site in an HHS-specified format and also submit this information to HHS, in a format and at times determined by HHS.
( e ) For plan years beginning on or after January 1, 2017, a health plan providing essential health benefits must have the following access procedures: ( 1 ) A health plan must allow enrollees to access prescription drug benefits at in-network retail pharmacies, unless: ( i ) The drug is subject to restricted distribution by the U.S. Food and Drug Administration; or
( ii ) The drug requires special handling, provider coordination, or patient education that cannot be provided by a retail pharmacy.
( 2 ) A health plan may charge enrollees a different cost-sharing amount for obtaining a covered drug at a retail pharmacy, but all cost sharing will count towards the plan's annual limitation on cost sharing under § 156.130 and must be accounted for in the plan's actuarial value calculated under § 156.135.
( f ) If a health plan covers prescription drugs in excess of the prescription drugs required to be covered under paragraph (a)(1) of this section, the additional prescription drugs are considered an essential health benefit and subject to requirements including the annual limitation on cost sharing and the restriction on annual and lifetime dollar limits, unless coverage of the drug is mandated by State action and is in addition to an essential health benefit pursuant to § 155.170, in which case the drug would not be considered an essential health benefit.
[78 FR 12866, Feb. 25, 2013, as amended at 79 FR 30350, May 27, 2014; 80 FR 10871, Feb. 27, 2015; 81 FR 12349, Mar. 8, 2016; 81 FR 53032, Aug. 11, 2016; 89 FR 26425, Apr. 15, 2024]