Resolution Ensuring Patient Protections Remain in Place in Medicaid Pharmacy Benefits Exposed

The Resolution Ensuring Patient Protections Remain in Place in Medicaid Pharmacy Benefits was considered by ALEC's Health and Human Services Task Force at the 2011 States and Nation Policy Summit on December 2, 2011. This bill was part of the ALEC task force agenda between 2010 and 2012, but due to incomplete information, it is not known if the bill passed in a vote by legislators and lobbyists at ALEC task force meetings, if ALEC sought to distance itself from the bill as the public increased scrutiny of its pay-to-play activities, or if key operative language from the bill has been introduced by an ALEC legislator in a state legislature in the ensuing period or became binding law.

ALEC Draft Bill Text

SUMMARY

This resolution urges state officials to implement certain safeguards and patient protections if the state’s Medicaid pharmacy benefits are transitioned from a fee-for-service setting to managed care.

MODEL RESOLUTION

WHEREAS, Medicaid provides health care and prescription drug coverage to the state’s most vulnerable patients; and

WHEREAS, Budgetary pressures and changes brought about by the Patient Protection and Affordable Care Act are causing some states to consider changing the way their state’s Medicaid pharmacy benefit is delivered; and

WHEREAS, An increasing number of states are shifting their Medicaid pharmacy benefit from a fee-for-service (FFS) model to a Medicaid managed care model (MCO); and

WHEREAS, It is critical that the preferred drug list (PDL) requirements and protections currently afforded patients in FFS remain in place as states make changes to their Medicaid pharmacy benefit; and

WHEREAS, Such PDL requirements and patient protections will help ensure continued access to and quality of care for Medicaid patients whose pharmacy benefit is shifted to Medicaid managed care; and

WHEREAS, Important patient protections currently exist in states that employ a FFS Medicaid pharmacy benefit model as required by Section 1927 of the Social Security Act; and

WHEREAS, Section 1927 of the Social Security Act generally requires, at a minimum, that there be open Pharmacy and Therapeutics (P&T) Committee meetings; that any prior authorization (PA) requests be responded to within 24 hours; and also requires coverage of branded products where a Medicaid rebate is offered and sets forth minimum PDL requirements; and

WHEREAS, Section 1927(d)(5)(B) of the Social Security Act allows for PAs only if the approval system in place can provide a response to the request, by phone or other telecommunications device, within 24 hours. In addition, pursuant to section 1927, states are required to provide for the dispensing of at least a 72-hour supply of a drug in emergency situations. These protections are no less important, or meaningful, in managed Medicaid; and

WHEREAS, Prescription drug coverage plays a critical role in a patient’s overall treatment, and ensuring that sufficient therapeutic options are available is important to the quality of patient care; and

WHEREAS, Physicians are best able to make treatment decisions for their patients based on the patient’s medical history, drug history, and physical and/or mental condition; and Resolution Ensuring Patient Protections Remain in Place in Medicaid Pharmacy Benefits 1

WHEREAS, Physicians should ultimately determine the prescription drug therapy, or other treatment, that is best for their patient; and

WHEREAS, Medicaid patients shifted to Medicaid managed care should receive at least the same coverage of and access to prescription drugs as they received under FFS; and

WHEREAS, An independent and transparent P&T Committee that meets certain minimum requirements is essential to helping ensure robust formulary coverage and sufficient access to meet patient needs; and

WHEREAS, While formulary management tools can provide an effective means to help ensure appropriate drug utilization and manage costs, it is important that such tools not create barriers to access. P&T Committees can play an important role in monitoring and appropriately implementing formulary management tools; and

WHEREAS, In order to help prevent formulary management tools—like prior authorization, step therapy, or generic “fail first”—from limiting physician choice and decision-making, it is important that certain guidelines for their implementation be established.

NOW THEREFORE IT BE RESOLVED THAT, {Insert state} should be free to choose how the Medicaid pharmacy benefit is delivered as long as the state has strong and specific patient protections in place that, among other things, respect the prescriber’s treatment recommendation(s) and ensure coverage of and access to a broad range of generic and branded prescription drug therapies; and

BE IT FURTHER RESOLVED THAT, {Insert state legislative body} urges adoption of the following criteria, if {insert state}’s Medicaid pharmacy benefit is shifted to the MCO setting:

1. The PDL for the Medicaid MCO is no more restrictive than the state’s FFS PDL;

2. The MCO PDL is developed and reviewed by an independent P&T Committee;

3. A P&T Committee reviews the MCO’s medication therapy management tools for appropriateness;

4. MCOs adopt a fair, transparent and uniform process for handling PAs and appeals; and

5. Physicians are empowered to make the final decision regarding the best course of therapy for their patients; and

BE IT FURTHER RESOLVED THAT, {Insert state}’s Medicaid officials examine the Texas and Florida models, which have been successful in working to implement important patient protections and safeguards.