MAMSI Follows Growing Trend, Excludes Coverage of Heartburn Drug

On June 29, the Federal Drug Administration (FDA) approved the sale of Prilosec, a widely prescribed medication for frequent heartburn, as an over-the-counter (OTC) drug. On September 15, 2003, Prilosec became available without a prescription at the exact same strength and dosage.

Since MAMSI pharmacy products, like most health insurance carriers, exclude coverage for OTC medications, Prilosec and its generic equivalent, Omeprazole, are no longer covered for new prescriptions by MAMSI health plans. Existing prescriptions (prescriptions written and filled prior to September 15, 2003) will continue to be filled until January 1, 2004.

Prescriptions for therapeutic equivalents, such as Prevacid, Nexxium, Protonix and Aciphiex, will require prior authorization in order to be covered under the member’s prescription drug policy. All WANADAês health plans under MAMSI will approve coverage for Prilosec’s therapeutic equivalents if the member: (1) tried and failed OTC Prilosec; or (2) filled a prescription within the last 90 days for any of Prilosec’s therapeutic equivalents.

MAMSI is informing all participating physicians of these changes and is sending correspondence, including a coupon for the new OTC Prilosec, to all members who have filled a prescription for a heartburn medication.

In what appears to be a growing trend in healthcare markets across the U.S., more medications are moving from prescription to OTC. AETNA has also announced policy adjustments similar to MAMSI and we expect other health insurance carriers to follow suit. This is not good news to consumers who will end up paying more for OTC drugs than prescriptions drugs covered by their health insurance.

However, one solution available to dealers is to set up tax exempt Flexible Spending Accounts (FSA) for their employees through WANADA. The IRS recently made new adjustments to –Section 125, FSAs that are likely to include the cost of some, but not all, OTC medications. The tax exempt FSAs are a great way to offset at least part of the cost of OTC drugs.

For more information on WANADAês FSA plans, contact John OêDonnell, (202) 237-7200.