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Medicaid Pharmacy Benefit goes to Managed Care October 1!

Medicaid Changes

Some major changes occurred in the Medicaid pharmacy program due to passage of HB 153, the budget bill.  As we notified you previously, the Medicaid pharmacy benefit is being carved back into managed care.  This will take place on October 1, 2011.  The Medicaid managed care plans that currently administer the medical benefit will take over the pharmacy benefit when it is carved in.  They are:  Amerigroup, Buckeye, CareSource, Molina, Paramount Advantage, United Community Plan, and WellCare.

The State of Ohio is going to re-procure the Medicaid managed care program and will be requesting proposals at the end of July/beginning of August.  Any plan selected will begin on July 1, 2012.

Unfortunately, the Medicaid dispensing fee remains at $1.80.  The Governor was successful at inserting it in the budget.  We worked very hard to have the dispensing fee raised, but due to the $8 billion budgetary hole that Ohio was trying to fill, we were unsuccessful.  Because the pharmacy benefit is going back to managed care on October 1, 2011, the population that this $1.80 dispensing fee affects is the population not included in managed care.  This includes dual eligibles (Medicare/Medicaid), disabled children, institutionalized individuals, individuals in waiver programs, and individuals who have a spend-down.

Dispensing Fee.

We do intend to pursue legislation to increase the dispensing fee and require more frequent updates of the formulary pricing.  It is notable that CMS hasn’t yet approved the Ohio State Plan Amendment (SPA), that dropped the dispensing fee to $1.80, that was filed over a year ago.  We are also actively working on getting CMS to disapprove the SPA.  If you haven’t already contacted your state representative and state senator, please do so and let them know how damaging this rock bottom dispensing fee is to your pharmacy.

New Restrictions on Prior Approval.

The budget bill placed restrictions on Medicaid managed care plans in regards to antidepressants and antipsychotics.  The law prohibits health insuring corporations (HICs) participating in Medicaid managed care from imposing prior authorization requirements for mental health drugs that are antidepressants or antipsychotics, with the following conditions: 1) the drugs must be in standard tablet or capsule form, but allows antipsychotics to also be in a long-acting injectable form; and 2) the drugs must be prescribed by a psychiatrist credentialed by the HICs or a psychiatrist practicing at a certified community mental health agency.

The law also prohibits HICs participating in Medicaid managed care from imposing prior authorization requirements if the recipient was being treated with antidepressants or antipsychotics or the drug was prescribed by any other health professional who was treating a Medicaid recipient immediately before Medicaid managed care resumes coverage of prescription drugs, but only for a 120-day period.  It also requires that Medicaid managed care organizations maintain coverage for all drugs for a 90-day period without using drug utilization or management techniques that are more stringent for a Medicaid recipient than before the recipient’s coverage is transferred to the managed care plan.


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