September 2020: Medicaid Common Formulary Changes

Written by: Courtney Sorenson, PharmD Candidate and Paige Thomey, PharmD Candidate

Key Points

  • As of October 1, 2020, all Michigan Medicaid formularies will consolidate to a single drug list called the Medicaid Preferred Drug List (PDL)
  • Most Medicaid plans will be sending both provider and patient level communication if they are impacted by this change
  • This consolidation will maximize rebates and lead to increased pharmacy reimbursement rates

All Michigan Medicaid formularies will be coming together as of October 1, 2020 to a single drug list. This is a change from the current state of each Medicaid plan being able to offer slight adjustments beyond the common formulary. This change should simplify the need to know multiple Medicaid formulary carveouts and exceptions. As recommended in the Governor’s Executive Budget, the Michigan Department of Health & Human Services will instead be implementing a single Medicaid Preferred Drug List (PDL). The Michigan Health Plan Common Formulary will be reviewed quarterly and changes made to the formulary will be reflected in the drug formulary documents.1,2

As this change is still being finalized, updated information can be found at: https://michigan.magellanrx.com/provider/

The PDL can be found at: https://michigan.magellanrx.com/provider/external/medicaid/mi/doc/en-us/MIRx_PDL.pdf

Relevant Changes for Patients2

  • Some products may not be covered as a pharmacy benefit, but instead will be identified as a medical benefit:
    • Physician-administered injectable drugs
    • Immunizations
    • Intrauterine devices
  • A standard prior authorization form was created
  • Mandatory Generic Drug Policy
    • For drugs with a generic form available, the brand-name will become non-formulary
  • Unit dose packaged product coverage may be less restrictive and covered on a case-by-case basis

Relevant Changes for Providers and Pharmacists3

  • The single Medicaid PDL will maximize manufacturer rebates
  • This policy also proposes raising the Medicaid Health Plan dispensing fee for independent pharmacies to $3
  • Reductions in budget of $182.9 million from Medicaid pharmacy reimbursement reform ($45.8 million from general fund) is tied to implementation of a single, statewide Medicaid PDL
  • The Medicaid PDL will help maximize federal rebates and provides the Michigan Department of Health & Human Services greater leverage in negotiating lower prices with drug manufacturers
  • Savings will be used, in part, to increase pharmacy reimbursement rates to further enhance access to provider networks throughout the state

Notable Exceptions and Changes in Medication Coverage*

  • Diabetes
    • Preferred agents will include some brand name items (e.g. Humalog® U-100 and Novolog® U-100) rather than generic options
  • Asthma/COPD
    • Preferred agents will include some brand name items (e.g. Advair Diskus®) rather than generic options
  • Gastrointestinal products
    • Preferred agents will include some brand name items (e.g. Lialda®) rather than generic options
  • Mental health
    • Preferred agents will include some brand name items (e.g. Adderall XR®) rather than generic options
  • Opioid use disorder
    • Preferred agents will include some brand name items (e.g. Suboxone® SL Films) rather than generic options

*Please check the online PDL for up to date coverage. This information is accurate as of August 2020.

References

  1. MDHHS – Medicaid Health Plan Pharmacy Benefit. Accessed July 28, 2020. https://www.michigan.gov/mdhhs/0,5885,7-339-71547_4860-380454–,00.html
  2. MDHHS Medicaid Health Plan Common Formulary. Published online July 23, 2020. Accessed July 28, 2020. https://www.michigan.gov/documents/mdhhs/General_MCO_Common_Formulary_Information_554126_7.pdf
  3. Whitmer G, Kolb C. Executive Budget Fiscal Year 2021 and 2022. Published online February 6, 2020. https://www.michigan.gov/documents/budget/FY2021_Executive_Budget_680297_7.pdf

Leave a Reply

Keep updated on COVID-19 by entering our secure Member's Portal.ENTER HERE >