How Medicaid Covers Prescription Costs

Understanding Medicaid Prescriptions

Navigating healthcare coverage can be complex, especially when it comes to prescription medications. For those covered by Medicaid, understanding how prescription coverage works is an essential part of managing one's health. This section provides insights into the basics of Medicaid prescription coverage and the Medicaid Drug Rebate Program.

Basics of Medicaid Prescription Coverage

Medicaid, a federal and state health coverage program, provides coverage for various health services, including prescription medications. The specifics of prescription coverage can vary by state and plan, but generally, Medicaid covers a wide range of both prescription and non-prescription drugs that are deemed medically necessary.

In the state of New York, for example, the NYRx program covers both prescription and non-prescription drugs approved by the FDA for Medicaid members. To be covered, prescription drugs require a prescription order with appropriate information, while non-prescription drugs require a fiscal order containing the same information as a prescription order [1].

How the Medicaid Drug Rebate Program Works

The Medicaid Drug Rebate Program is a key component of Medicaid prescription coverage. This program requires drug manufacturers to provide rebates to Medicaid for covered outpatient drugs. In return, Medicaid provides coverage for most of the drugs made by these manufacturers.

The rebate amount is determined by several factors, including the drug's classification and the manufacturer's price. The program helps to offset the cost of prescription drugs for Medicaid, allowing the program to provide a broader range of medications to its members.

While the program helps lower the overall costs of drugs, it's important to note that certain drugs or drug categories may require prescribers to obtain prior authorization before Medicaid members can access them. More information on this requirement can be found in the New York State Medicaid State Plan Amendment [1].

Understanding the basics of Medicaid prescription coverage and the Medicaid Drug Rebate Program can help beneficiaries better manage their health care needs. For more detailed information on Medicaid prescriptions, beneficiaries can refer to resources provided by their state's Department of Health or reach out to their Medicaid program directly. In New York State, for example, detailed information on the pharmacy program and billing policy can be accessed in the NYS MMIS Pharmacy Provider Manual and the Department's Medicaid Update [1].

State Variations in Medicaid Prescriptions

Medicaid prescriptions follow guidelines at the state level, resulting in variations across different states. These variations manifest in formulary differences and limitations or caps on medications.

Formulary Differences Across States

Every state maintains its own list of approved drugs, also known as a formulary, for Medicaid coverage. These formularies differ from state to state, meaning a drug covered under Medicaid in one state might not be covered in another. Certain drugs or drug categories may also require prescribers to obtain prior authorization before Medicaid members can access them. More information on this requirement can be found in the New York State Medicaid State Plan Amendment. (New York State Department of Health)

Limitations and Caps on Medications

In addition to formulary differences, states also vary in the limitations they place on prescriptions under Medicaid. As of 2021, 33 states limited the number of prescription drugs that Medicaid patients could fill in a given month. (KFF)

These prescription caps have seen an upward trend over the years. The number of states with Medicaid prescription caps increased from 12 in 2001 to 20 in 2010. Data suggests that overall cap implementation led to a 0.52% annual decrease in the proportion of essential prescriptions, but no change in cost. On the other hand, caps on brand-name drugs led to an immediate 2.29% decrease in branded prescriptions and a 1.26% decrease in spending. (PubMed)

The impact of these caps extends to the use of preventive essential medications, with overall cap implementation resulting in a 1.12% annual decrease. This equates to an estimated savings of 246,000 prescriptions and $12.2 million annually. In terms of brand-name drugs, cap implementation led to a 0.74% decrease in branded prescriptions and a corresponding 0.79% increase in generic prescriptions, with estimated savings of $17.4 million. (PubMed)

While prescription caps might seem like a cost-saving measure, they have been implemented despite evidence of clinical harms and negative impacts on medication utilization and spending. In fact, prescription drugs cost Medicaid almost $390 billion in 2010. (PubMed)

In essence, navigating the landscape of Medicaid prescriptions requires an understanding of the state-specific differences. This includes formulary variations and the potential impact of limitations or caps on medications. Understanding these factors can help beneficiaries make the most of their Medicaid coverage when it comes to prescription drugs.

Medicaid and Over-The-Counter Medications

The Medicaid Prescription Drug Program extends beyond traditional prescription medications. It also offers coverage for over-the-counter (OTC) medications in certain situations. The specifics of this coverage, however, can vary and depend on criteria set by individual states and the role of prescriptions.

Criteria for Over-The-Counter Coverage

The Medicaid Prescription Drug Program provides coverage for over-the-counter medications when prescribed by a provider for Medicaid beneficiaries [2]. While the coverage includes a wide range of medications, each state's program has its own list of covered drugs, known as a formulary. These formularies can restrict coverage to specific drugs or drug classes, which can affect beneficiaries' access to certain medications.

States administer their Medicaid pharmacy benefits differently, but all adhere to federal guidelines regarding pricing and rebates. Due to Medicaid's role in financing coverage for high-need populations, it pays for a disproportionate share of high-cost specialty drugs. This poses challenges for state policymakers in managing prescription drug spending.

Role of Prescription in Coverage

In the context of over-the-counter medications, the role of a prescription is crucial. For an OTC medication to be covered under the Medicaid Prescription Drug Program, it must be prescribed by a provider. This ensures that the medication is necessary for the health and well-being of the Medicaid beneficiary.

The Medicaid Drug Rebate Program mandates that manufacturers who want their drugs, including OTC medications, covered under Medicaid, must offer rebates to the government. This ensures that Medicaid receives rebates based on the "best price" available to other buyers, with some exceptions. In return, Medicaid covers almost all FDA-approved drugs from those manufacturers.

Medicaid reimburses pharmacies based on the actual acquisition cost (AAC) for a drug, using the National Average Drug Acquisition Cost (NADAC) data as a measure of AAC. States have flexibility in setting professional dispensing fees, but pricing and rebates from manufacturers are subject to federal guidelines.

Understanding the criteria for over-the-counter coverage and the role of prescription in this coverage can help Medicaid beneficiaries navigate their benefits more efficiently. This knowledge can contribute to improved health outcomes and better management of healthcare costs.

Medicaid Prescription in New York

For Medicaid beneficiaries in New York, it's vital to understand how the state's specific program, NYRx, covers prescriptions. This program has specific guidelines and requirements, and members are advised to refer to the resources provided by the Department of Health for detailed information on how to use the program effectively.

Transition to NYRx

The New York State Medicaid Pharmacy program, NYRx, covers medically necessary FDA approved prescription and non-prescription drugs for Medicaid members. Prescription drugs require a prescription order with appropriate required information. Non-prescription drugs require a fiscal order that contains the same information as a prescription order.

Starting April 1, 2023, Medicaid members enrolled in mainstream Managed Care (MC) plans, Health and Recovery Plans (HARPs), and HIV-Special Needs Plans (SNPs) will have their pharmacy benefits transitioned to NYRx. This transition does not apply to members enrolled in Managed Long-Term Care plans (e.g., PACE, MAP, and MLTC), the Essential Plan, or Child Health Plus.

Identifying Prior Authorization Drugs

Certain drugs or drug categories may require prescribers to obtain prior authorization before Medicaid members can access them. More information on this requirement can be found in the New York State Medicaid State Plan Amendment.

Prescribers, pharmacists, and beneficiaries can access detailed information on the pharmacy program and billing policy, as well as other pharmacy-related information, in the NYS MMIS Pharmacy Provider Manual and the Department's Medicaid Update. For Medicaid pharmacy policy related questions, individuals can reach out via email at NYRx@health.ny.gov or by phone at (518) 486-3209.

The transition to NYRx and the identification of prior authorization drugs underscore the complexity of Medicaid prescriptions in New York. As such, beneficiaries are encouraged to familiarize themselves with these changes and requirements to make full use of their benefits.

Role of Medication Therapy Management

Medication Therapy Management (MTM) programs play a crucial role in the Medicaid prescription drug coverage process. These programs focus on improving therapeutic outcomes for beneficiaries via optimized medication use, leading to potential cost savings and improved health outcomes.

Purpose of MTM Programs

MTM programs are designed to aid in the management of medication therapies for Medicaid beneficiaries. The primary goal of these initiatives is to ensure effective use of prescription drugs, thereby enhancing the health outcomes of the individuals enrolled in the program. This is achieved through a comprehensive approach that includes reviewing the patient’s medication regimen, identifying any potential issues, and proposing solutions to optimize therapeutic results.

MTM programs serve a crucial role in monitoring and managing the medication therapies of beneficiaries, particularly those with chronic conditions who are often prescribed multiple medications. They provide a structured and systematic approach to medication management, ensuring that the patient’s medications are appropriate, effective, safe, and are being used as intended.

Benefits of MTM for Beneficiaries

The benefits of MTM programs extend beyond improved health outcomes. These programs also offer potential cost savings for beneficiaries as well as the Medicaid program itself. By optimizing medication use, MTM programs can help to prevent costly health complications that may arise from improper medication use.

Beneficiaries of MTM programs can expect personalized care that takes into account their unique health needs and medication regimen. This includes a comprehensive review of all their medications, including prescription drugs, over-the-counter medications, and dietary supplements. If any issues are identified, such as potential drug interactions or unnecessary medications, the MTM program can propose changes to enhance the beneficiary’s health and safety.

In turn, effective MTM programs can lead to cost savings for the Medicaid program. By preventing adverse drug events and improving medication adherence, these programs can help to reduce hospital admissions and emergency department visits, which are significant cost drivers in healthcare.

In conclusion, MTM programs are an essential component of Medicaid's prescription drug coverage, providing valuable benefits for beneficiaries and contributing to the overall efficiency and effectiveness of the program. These programs exemplify a proactive, patient-centered approach to healthcare, emphasizing the importance of proper medication use in achieving optimal health outcomes.

Cost Factors in Medicaid Prescriptions

Understanding the role of cost factors in Medicaid prescriptions is essential for beneficiaries, caregivers, and healthcare providers. This section explores how rebates and prescription caps impact drug costs under Medicaid.

Impact of Rebates on Drug Costs

The Medicaid Drug Rebate Program plays a pivotal role in controlling the cost of Medicaid prescriptions. This initiative mandates drug manufacturers to provide rebates to state Medicaid programs for covered outpatient drugs. If manufacturers want their drugs to be covered by Medicaid, they are obliged to participate in this rebate program.

Medicaid reimburses pharmacies based on the actual acquisition cost (AAC) for a drug, using the National Average Drug Acquisition Cost (NADAC) data as a measure of AAC. While states have flexibility in determining professional dispensing fees, pricing and rebates from manufacturers are subject to federal guidelines.

Despite these rigid guidelines, managing prescription drug spending remains a challenge for state policymakers, especially considering Medicaid's role in financing coverage for high-need populations. This is particularly true in light of Medicaid's responsibility to cover high-cost specialty drugs and upcoming "blockbuster" drugs [3].

Impact of Prescription Caps on Costs

Another key cost factor in Medicaid prescriptions is the implementation of prescription caps. According to a study published on PubMed, the number of states with Medicaid prescription caps increased from 12 in 2001 to 20 in 2010.

Here's how the implementation of these caps impacted prescriptions and costs:

Overall cap implementation led to a slight annual decrease in the proportion of essential prescriptions, but it didn't affect the cost. On the other hand, the implementation of brand caps resulted in an immediate decrease in branded prescriptions and a slight decrease in spending.

Interestingly, both overall cap and brand cap implementation led to a decrease in the use of preventive essential medications and an increase in generic prescriptions, resulting in significant annual savings.

Clearly, rebates and prescription caps are two major factors affecting the cost of Medicaid prescriptions. Understanding their role can help beneficiaries and healthcare providers make informed decisions about medication use and spending.

References

[1]: https://www.health.ny.gov/health_care/medicaid/program/pharmacy.htm

‍[2]: https://www.medicaid.gov/medicaid/prescription-drugs/index.html

‍[3]: https://www.kff.org/medicaid/fact-sheet/medicaids-prescription-drug-benefit-key-facts/