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With Carmen Paun

THE ‘NO-COST’ QUESTION — HHS and other agencies are culling through feedback they requested on whether health plans should be required to cover over-the-counter preventive items at no out-of-pocket cost without a prescription for the OTC product.

Such a move by HHS and the Treasury and Labor departments would transform the way consumers could access birth control, smoking cessation items and other products. The Biden administration hopes it could be a boon for health equity and fighting systemic racism.

Insurers and the pharmacy benefit managers that negotiate prescription drug costs broadly support their goal of ensuring affordable access to OTC preventive products for consumers — but urge caution.

With a comment period that closed Monday, insurers, employee benefits groups and PBMs want guardrails against overuse and fraud, including purchases made by ineligible persons or those buying products to resell. The ERISA Industry Committee, which represents large employers’ benefit interests, warned that if not properly implemented, such a plan could cause premiums and costs to rise.

“Such overuse and misuse will contribute to increased health care spending, and such increased health care spending will ultimately be borne by the plan sponsor and its participants in the form of higher premiums,” ERIC wrote.

Some suggestions from insurers, PBMs and other groups included:

Requiring prescriptions: The Alliance of Community Health Plans and alternative PBM Navitus Health Solutions called for prescriptions to be required. ACHP said the setup would allow claims to be processed at the counter and could help avert safety issues, and Navitus argued it could help curb overuse and costs.

Other groups like the insurer lobby AHIP called for a “phased approach” to no-cost coverage of OTC products without a prescription, beginning with contraception.

Covering in-network: Insurers and a top PBM lobbying group, the Pharmaceutical Care Management Association, said if in-network providers are available, plans shouldn’t have to cover services out of network. Without such a requirement, AHIP argued, some retailers and manufacturers could hike prices.

Addressing practical challenges: To expand access, AHIP called for a wide variety of options for consumers, including a “debit card-like” method, online purchasing and post-purchase reimbursement.

Navitus said no systems are in place to deal with reimbursement and called on the agencies to allow “flexibility and time” to develop ways of implementing a potential mandate. ERIC called for the agencies to “clearly categorize” eligible items in a list.

WELCOME TO WEDNESDAY PULSE. Nearly half of Americans say they would be open to buying prescription drugs from a non-FDA-approved source online if they couldn’t otherwise get it, according to a new ASOP Global Foundation-commissioned survey.

Reach us at [email protected] or [email protected]. Follow along @_BenLeonard_ and @ChelseaCirruzzo.

TODAY ON OUR PULSE CHECK PODCAST, host Lauren Gardner talks with POLITICO health care reporter Ruth Reader, who explains why legislators are worried that tech companies like Google are too quickly deploying artificial intelligence in health care products and services before regulations protecting patients are set.

VET SUES OVER EHR — Vietnam vet Charlie Bourg is suing the Department of Veterans Affairs for negligence in implementing its troubled electronic health records overhaul. He’s also suing EHR contractor Oracle Cerner over defects in their system.

In a lawsuit filed in federal court in Washington state, Bourg, who has terminal cancer, seeks unspecified damages. In December 2020, when a test showed Bourg might have prostate cancer, his doctor tried to send a referral to a specialist, the complaint said. But the Cerner digital system routed the order to an unknown queue, and the appointment wasn’t scheduled. That, he says, led to a 17-month delay in diagnosis.

“My time may be short, but I will not go quietly. The people at the top need to be held accountable,” Bourg said in a statement.

The VA and Oracle Cerner didn’t respond to requests for comment.

The backdrop: VA has been attempting to modernize its digital health records system for years, but new rollouts have been on pause since April amid cost overruns and safety issues. The software has been launched in only five VA facilities, and as of October, clinicians were still filing complaints and raising concerns about patient safety.

TUBERVILLE THROWS IN THE TOWEL — Sen. Tommy Tuberville (R-Ala.) is ending his monthslong holds on military nominations over the Pentagon’s abortion policy, backing off his pledge to block them until the agency changes its policy, POLITICO’s Ursula Perano and Burgess Everett report.

Tuberville told reporters Tuesday he will keep holds on 12 four-star general nominees but lifted the rest, allowing the Senate to approve more than 400 promotions Tuesday.

The Pentagon’s policy allows service members to be reimbursed if they need to travel out of state to receive an abortion.

The move comes after months of pressure and frustration from fellow Republicans, as Tuberville’s opposition delayed hundreds of promotions. Tuberville had weighed other solutions, including a lawsuit over the policy, but said he didn’t have regrets about his strategy.

“I think we saw some success,” Tuberville said of his tactics, though he didn’t elaborate on what he meant.

SENATE SUPPLEMENTAL KEEPS FENTANYL MONEY — A Senate supplemental package released by Senate Appropriations Chair Patty Murray (D-Wash.) contains the $1.2 billion requested by the Biden administration to fight fentanyl and legislation allowing sanctions on fentanyl cartels and demands the administration completes a series of reports on its efforts to curb fentanyl trafficking, Carmen reports.

Most of the fentanyl money — just over $1 billion — would go to the Department of Homeland Security to combat the entry of fentanyl and other illicit narcotics into the U.S.

The fentanyl sanctions legislation, called the FEND Off Fentanyl Act, was approved unanimously by the Senate Banking Committee in June.

The Senate is expected to take an initial vote on the legislation today, which Republicans are widely expected to block over disagreement regarding border security.

HOUSE CHECKUP — The House is set to vote on a GOP-led health care package next week that was pulled from the schedule in September, according to the House floor calendar updated on Tuesday, POLITICO’s Megan R. Wilson reports.

The legislation — negotiated among the three committees with jurisdiction on health issues — would usher in increased transparency requirements for insurers, hospitals and pharmacy benefit managers.

Why it matters: The measure stakes the House’s claim on key issues Congress has considered this year and would reauthorize a number of federal programs set to expire, including a fund for community health centers and another that extends research into cures for diabetes. Pharmacy benefit managers and hospitals oppose the legislation.

The vote: The House will vote to advance the bill under suspension, an expedited process that means leadership is confident it will receive the required two-thirds majority vote. Rep. Bobby Scott (D-Va.), ranking member of the Committee on Education and the Workforce, supports the legislation after not backing it previously, a person familiar with the negotiations told Pulse.

In E&C: The House Energy and Commerce Committee is set to mark up a bevy of health care bills addressing a wide range of issues in the sector today.

The 44 bills include legislation that would provide more transparency in CMS’ national coverage determination process and for pharmacy benefit managers and address telehealth privacy and compliance burdens. Many of the bills impact Medicare, including a proposal addressing doctor pay.

Also in the chamber: The House passed the Elizabeth Dole Home Care Act in a 414-5 vote on Tuesday. The legislation would expand caregiver support for veterans who live in the community.

FIRST IN PULSE: BIG AD BUY — The Coalition to Protect America’s Health Care is debuting a seven-figure TV and digital advertising effort slamming insurers.

The hospital-tied group is hitting payers for what they see as “denying essential care” and increasing health care costs. It comes as hospitals are fighting potential legislation that could impact their bottom lines.

Lexi Branson is now deputy vice president for advocacy and strategic alliances for PhRMA. She previously was executive director of federation programs and grassroots for the U.S. Chamber of Commerce.

Kimberly Westrich has been named chief strategy officer at the National Pharmaceutical Council. She’s returning to the organization after a stint at Cencora.

Yael Lehmann has been appointed as interim executive director of Families USA after Frederick Isasi recently said he will step down. Lehmann was appointed recently to be the group’s senior director of strategic partnerships.

Healthcare Dive reports on CMS saying that states could have federal funding yanked if they don’t follow rules related to Medicaid unwinding.

Endpoints News reports on pharma companies’ race to get into obesity treatment development.