Proposal Would Transition Coverage for Some Drugs to Medicaid Health Plans

Posted on July 25, 2019

The Medical Services Administration (MSA) recently released a proposed policy to streamline prescription drug coverage policies and enhance medical management of complex drug therapies. Currently, certain drugs prescribed to Medicaid health plan (MHP) enrollees are covered by Medicaid fee-for-service. Under the proposed policy, those drugs would be covered by the MHP effective Oct. 1.

The proposal includes an appendix listing the drug classes that the MSA recommends be covered by the MHPs. The plans would be required to continue coverage through Dec. 31, 2019, for drugs prescribed to MHP enrollees that are in a class reflected on the appendix and are not on the MHP common formulary, as well as for drugs that require prior authorization (PA). The extended coverage would allow the enrollee time to obtain PA without interrupting their drug therapy.

PAs currently in effect for drugs that would be transitioned to MHP coverage would remain effective through the PA period for MHP enrollees (including Children’s Special Health Care Service beneficiaries). For MHP enrollees who are currently taking a drug that would transition to MHP coverage, MHPs would be required to send advance notice to both the enrollee and the prescriber. The notice would need to outline PA requirements and options and be sent no later than Oct. 1.

Hospitals are encouraged to submit comments on the proposal to the MSA by Aug. 22, as noted in the proposed policy. Members with questions should contact Vickie Kunz at the MHA.  

Tags: Medicaid, prescription drugs, MSA, proposed policy

Posted in: Member News

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