The California Department of Managed Health Care has directed California HMOs not to exclude coverage for an entire class of prescription medications when one drug in that class gains over-the counter status - DMHC - OTC - Drug Cost Strategies in Brief - Brief Article

Drug Cost Management Report, April, 2003

* The California Department of Managed Health Care (DMHC) has directed California HMOs not to exclude coverage for an entire class of prescription medications when one drug in that class gains over-the counter (OTC) status. The advisory notice was released on March 13 after the department recognized that health plan enrollees may have trouble obtaining coverage for prescriptions in a certain drug class after one particular drug has recently been made available without a prescription.

The department says the advice should not be interpreted as restricting any previously approved pharmacy benefit structures that include copayments, tiering and prior authorization. Since the OTC version of the popular nonsedating antihistamine (NSA) Claritin (loratadine) became available, health plans have begun to change their formularies, whether that means removing Claritin from the formulary, moving it and similar drugs to a higher tier, or eliminating coverage of the entire class of NSAs (DCMR, March 2003). According to a nationwide survey of more than 1,000 allergy sufferers conducted by The Institute for Health and Productivity Management, over 50% of respondents believe their quality of life would decrease if NSAs were removed from their managed care drug formularies. Information: Katie Nitz, California Office of Legal Services, (916) 323-7078, or www.dmhc.ca.gov.