Operational Readiness Covering Prescription Digital Therapeutics

The Academy of Managed Care Pharmacy (AMCP) convened a focus group in March 2024 to discuss operationalizing the coverage of prescription digital therapeutics (PDTs) by health payers. The focus group was comprised of seven health payer experts from commercial health plans, pharmacy benefit managers, and state Medicaid programs. The focus group discussed the following issues:

• Evidentiary standards that justify coverage.
• Coding practices required to facilitate coverage.
• Considerations for benefit design.
• Unique supply chain and reimbursement requirements.
• Federal legislation that would authorize Medicare coverage of PDTs.

PDTs offer significant promise in treating certain conditions and improving access to care, but participants agreed that a new modality requires new approaches to coverage. This brief, which summarizes the focus group’s findings, is intended to help prepare the American health care system to begin covering PDTs.

• Health payer readers will learn about the unique considerations for evaluating PDTs for coverage and incorporating them into their benefit design.
• PDT developer readers will learn more about the needs of health payers to better inform the development of their products and informational materials.

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Learn more about our advocacy on Digital Therapeutics and the Access to Prescription Digital Therapeutics Act of 2023 (S.723/H.R. 1458), an important bipartisan bill that will improve care for millions of Americans by expanding coverage of prescription digital therapeutics (PDTs).