Medicaid Pharmacy "Carve-In" Effective October 1

The Ohio Department of Jobs and Family Services held a stakeholder meeting, September  14, to explain the new Medicaid pharmacy benefit "carve-in," effective October 1, 2011,.  The "carve-in" reverses pervious efforts by providers to establish a uniform prior authorization (PA) policy and preferred drug list under Medicaid fee for service (FFS) that all plans had to follow.  Physician groups pushed for the uniform policy several years ago after the seven Medicaid plans established different preferred drug lists and PA policies that created an administrative nightmare for physicians.  

Despite initial objections from the OOA, the Kasich administration returned control of the pharmacy benefit to the Medicaid Managed Care Plans with the promise that the previous inconsistencies among plans would be limited and streamlined to simplify the PA process.  

In developing the new carve-in and returning the pharmacy benefit to each plan, the seven Medicaid Managed Care Plans and the Ohio Department of Job & Family Services (ODJFS) collectively reviewed 4,270 drugs and agreed on 63.4 percent that will be automatically accepted by all without PA.  The goal was to reach 80 percent uniformity; however, the workgroup that analyzed prescription claims data said that 80 percent of all Medicaid prescriptions written won’t require a prior authorization.  About 3 percent of drugs currently on the FFS formulary will require prior authorization by all seven plans plus FFS; about 6 percent will require prior authorization by the seven plans, but not FFS; and 11 percent will have varying prior authorization with different preferred drugs across the seven plans.  

The general principles used to standardize PAs as much as possible were: (1) mandatory generic substitution; (2) inclusion for newly released generics as introduced for sole source name brands and when appropriate; (3) more expensive generic options for second-line therapy may require step therapy as second line agents; and (4) prescriptions written outside FDA labeling (dose, quantity limits, general, age diagnosis, etc.) may require PA for the first year on new brand name drugs.  

The websites for the plans, ODJFS and the Association of Health Plans will all include links to the various Preferred Drug/Prior Authorization Drug lists.  The plans have developed a common PA form, which can be downloaded at the Ohio Association of Health Plans website.  

Consistency among plans will be evaluated quarterly, and changes on consensus drugs will be limited to once a quarter, with very limited exceptions such as rapid drug price changes based on availability.  The Health Plan Workgroup will meet after the Medicaid Pharmacy and Therapeutics Committee reviews proposed changes for FFS, which will give interested parties an opportunity to provide input.  Robert L. Hunter, DO, and Ioanna Z. Giatis, DO, represent the OOA on the P& T Committee.  

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