Pennsylvania Health Insurers Must Cover Medication Synchronization Services Beginning July 2020

Beginning July 1, 2020, Pennsylvania’s Act 46 of 2019 (Act 46)[1] will require most Pennsylvania health insurers to cover medication synchronization services (MedSync) provided to patients taking two or more maintenance medications (i.e., medications for chronic long-term conditions, including diabetes, high blood pressure, and heart disease).  Act 46 has been well-received by health care stakeholders as it is expected to improve patient outcomes, and reduce health care costs, by making it easier for patients to access medication.  However, as Act 46’s MedSync coverage mandate approaches, pharmacies should promptly consider whether and how to best implement MedSync into their business practices.

At their core, MedSync services involve pharmacists coordinating refills of patients’ medications so each mediation can be picked up on the same day each month.  Although the concept of MedSync is rather straightforward, in practice it involves intensive review of a patients; medication profiles, appropriately adjusting drug regimes; and managing patient’s care on an ongoing basis.  Moreover, historical barriers such as insurance coverage limitations, patient co-payment obligations, and implementation hurdles have prevented pharmacies from effectively and efficiently providing MedSync services.  Due to historical coverage barriers, it is estimated only 5,000 of the nearly 67,000 pharmacies in the United States currently offer MedSync services.[2]

In effort to reduce health care costs and hospital readmission rates, as well as to improve patient quality of care, Act 46 requires affected Pennsylvania health insurers to:

1. cover fills of maintenance medications through MedSync services;
2. apply pro-rated daily cost sharing (i.e., copayment) rate to maintenance medications filled for MedSync purposes;
3. accept early refill and partial fill requests for MedSync service purposes;
4. pay pharmacy dispensing fees in full for any partial supply or refilled medication dispensed through MedSync services.[3]

Moreover, Act 46 expressly prohibits health insurers from implementing pharmacy payment structures using a pro-rated pharmacy dispensing fee.[4] 

However, despite Pennsylvania’s clear preference for MedSync coverage, Act 46 allows health insurers to restrict coverage of MedSync services to network pharmacies.[5]  As such, pharmacies should consider whether implementing MedSync services may differentiate the pharmacy from other providers and whether MedSync services are necessary to remain within Pennsylvania health insurance networks.

If you would like to learn more about Pennsylvania’s Act 46 or MedSync coverage services and requirements, please reach out to your Dinsmore attorney.