NCPA Proposes Criteria for Grandfathered Health Plans, Pharmacy Benefits

Alexandria, VA - August 17, 2010


The National Community Pharmacists Association (NCPA) submitted comments to the Internal Revenue Service (IRS), Employee Benefit Security Administration (EBSA), and the Department of Health and Human Services Office of Consumer Information and Insurance Oversight (OCIIO) supporting patient choice and greater utilization of generic prescription drugs, as those three agencies develop criteria for maintaining Grandfathered Health Plan (GHP) status under the Patient Protection and Affordable Care Act (PPACA).

"Providing quality patient care is vital to health care reform and health plans that want to maintain grandfathered health plan status should not be allowed to alter their structure and benefits in ways that undermine those objectives," said NCPA Acting Executive Vice President and CEO, Douglas Hoey, RPh. "For example, the face-to-face interaction patients get in their local pharmacies has a proven, positive track record in terms of health outcomes. Changes by health plans that steer patients against their will toward mail order pharmacies represent more than just 'reasonable routine changes' to an existing health plan and should cause them to lose grandfathered health plan status."

"Similarly, health plans should not be able to maintain grandfathered status when they change their prescription drug formulary designs by creating or expanding a list of 'specialty medications' in order to shift patients to a specific mail order pharmacy. Such changes will result in more limited beneficiary access to these drugs, as 'specialty medications' are likely not available to independent community pharmacies. These are more than 'reasonable routine changes' and should also cause them to lose their grandfathered status."

"On the other hand, when generic alternatives become available, the brand name prescription drug is routinely placed in a higher co-pay tier in the drug formulary to promote the use of the generic. That is indeed a 'reasonable routine change' and should not be grounds for a plan losing its grandfathered status."

NCPA believes that all of the recommendations above will benefit patients while adhering to the spirit and letter of the law.

The National Community Pharmacists Association (NCPA®) represents America's community pharmacists, including the owners of more than 22,700 independent community pharmacies, pharmacy franchises, and chains. Together they represent an $88 billion health-care marketplace, employ over 65,000 pharmacists, and dispense over 40% of all retail prescriptions. To learn more go to or read NCPA's blog, The Dose, at

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