Departments Issue Request for Information on Coverage of Over-the-Counter Preventative Items and Services

The federal government has recently opened a period of public comment regarding health plan coverage of over-the-counter medicines. This period of public comment will remain open until December 4, 2023.

On October 4, 2023, the Departments of Health and Human Services (HHS), Labor (DOL), and the Treasury (the Departments) published a request for information (RFI) that asks the public for comments on the costs and benefits of having non-grandfathered group health plans and issuers to cover over-the-counter (OTC) preventative items and services without cost-sharing and without a written prescription.

As background, under the Affordable Care Act (ACA), non-grandfathered group health plans and health insurers must provide coverage for certain preventive health services and cannot require participants and beneficiaries to share the cost of these services through copayments, coinsurance, or deductibles. Several of the recommended preventive items and services are currently available to consumers OTC without a prescription but are not required to be covered without cost-sharing unless prescribed by a healthcare provider.

With the RFI, the Departments are seeking information from the public to improve the Departments’ understanding of the issues regarding the costs and benefits of requiring non-grandfathered group health plans to cover OTC preventive products without cost-sharing and without a prescription.

The Departments are also seeking input on any operational challenges to plans, issuers, TPAs, PBMs, and retailers if they are required to cover OTC preventative items and services. In the recent past, the Departments have required coverage without cost-sharing for many items, including COVID-19 diagnostic tests. In addition, the Departments have issued regulations seeking to protect and expand access to reproductive healthcare services. In requesting comment, the Departments are looking for lessons learned from those in the industry.

Public comments are due within 60 days of the rule being published, which means all comments must be submitted by December 4, 2023.

Richard Lo, Clinical Services Director and pharmaceutical policy expert for OneDigital's Pharmacy Consulting division, had this to say about the Departments' request for information:

“Clinical and financial considerations must be reviewed with any class coverage change. Clinically, a mandated prescription allows another medical professional to review the treatment for clinical safety and additional guidance. Many OTC medications can interact with food, medical conditions, or other drugs, which further supports a review. Financially, it’s important to note that if these extra preventive items are required to be covered at no cost-share, it could lead to higher healthcare costs in the long run. When products are covered at “no cost” at the counter, it can potentially contribute to higher plan premiums, deductibles, and other out-of-pocket expenditures because the cost of said products must ultimately be assumed by somebody. Usually, said costs wind up trickling back to the plan member.”

— Richard Lo, Clinical Services Director, OneDigital Pharmacy Consulting

Want to learn more about employer-sponsored pharmacy benefits? Check out our post that covers 3 Ways Employers Overspend on Prescription Drugs.