Ama Policy

Third Party Payer Quantity Limits H-185.942

ERISA-Med. Nec. Appeals-Deadlines, ERISA-Med. Nec. Decisions-Deadlines, State Medical Necessity Appeals-Deadlines, State Medical Necessity Decisions-Deadlines, Step Therapy Override, U.R. Criteria

1. Our AMA supports the protection of the patient-physician relationship from interference by payers and Pharmacy Benefit Managers (PBMs) via various utilization control mechanisms, including medication and testing and treatment supply quantity limits.

2. Our AMA will work with third party payers and PBMs to ensure that if they use quantity limits for prescription drugs or testing and treatment supplies, an exceptions process must be in place to ensure that patients can access higher or lower quantities of prescription drugs or testing and treatment supplies if medically necessary, and that any such process should place a minimum burden upon patients, physicians and their staff.

3. Our AMA supports interested states legislative efforts and federal action and will develop model state legislation to ensure that third party payers or PBMs that institute quantity limits for prescription drugs or testing and treatment supplies include an exceptions process so that patients can access higher or lower quantities of prescription drugs or testing and treatment supplies if medically necessary, including provisions such as the following:

–    physicians can specify limited supplies of medications during initial trials of a medication, or if a larger quantity of medication would expose an at-risk patient to potential harm (e.g., opioids, benzodiazepines, or psychostimulants)

–    physicians can appeal adverse determinations regarding quantity limitations;

–    payers must provide an easily accessible list of all medications and testing and treatment supplies with quantity limits and the requirements for the exception process on the payer’s Web site;

–    payers must indicate, what, if any, clinical criteria (e.g., evidence-based guidelines, FDA label, scientific literature) support the plan’s quantity limitations;

–    physicians with specialized qualifications may not be subject to quantity limits;

–    payers cannot charge patients for an additional co-pay if an exception request for a higher medication or testing and treatment supply quantity has been approved based on medical necessity;

–    payer decisions on exception, and subsequent appeal requests, of quantity limits must be made within two working days in non urgent situations and one working day in urgent cases; and

–    physicians or patients can submit any denied appeals to an independent review body for a final, binding decision.

Policy Timeline

BOT Rep. 12, A-12 Reaffirmation: I-17; Modified: CMS Rep. 05, A-23