UM Compliance Requirements
| Requirement | Law | Compliance Action |
|---|---|---|
| MH/SUD PA parity | MHPAEA | Confirm PA requirements for MH/SUD drugs are no more restrictive than for medical drugs |
| Preventive drug coverage | ACA | Cover USPSTF-recommended preventive medications at $0 cost-sharing |
| Step therapy exceptions | State laws (varies) | Confirm step therapy programs include required exceptions |
| PA turnaround time | State laws (varies) | Confirm PA turnaround times meet state requirements |
| Appeals process | ERISA/ACA | Confirm appeals process meets ERISA and ACA requirements |
MHPAEA and Pharmacy UM
MHPAEA requires that PA and step therapy requirements for mental health and substance use disorder drugs be no more restrictive than for medical/surgical drugs. If your plan requires step therapy for antidepressants but not for cardiovascular drugs, you may have a MHPAEA violation. Review pharmacy UM programs for MHPAEA compliance annually.
ACA Preventive Drug Coverage
Compliance Note
ACA requires coverage of USPSTF-recommended preventive medications at $0 cost-sharing. This includes statins for cardiovascular prevention, aspirin for cardiovascular prevention, and PrEP for HIV prevention. Plans that impose cost-sharing for these medications are violating ACA. Review your formulary for ACA preventive drug compliance annually.