Recommendations to Restore Patient Protections for Medicaid Prescription Drug Coverage
The Prescription Drug Program enacted in 2005 ensured Medicaid beneficiaries a number of patient protections, including access to appropriate medication and clinical experts overseeing the Pharmacy and Therapeutics Committee managed Prescription Drug Lists. Additionally, doctors had ultimate authority in determining which medications were best for their patients. However, as part of a cost-saving measure in the 2011-12 Executive Budget, Medicaid pharmacy benefits were moved from a fee-for-service program to Medicaid Managed Care without adopting the aforementioned patient protections.
Under the new Managed Care program, "prescriber prevails" provisions that allow a health care provider to make final decisions regarding a patient's prescription drug regimen are not honored. Rather, Managed Care providers have imposed a prior authorization process and preferred drug lists of medications, developed to maintain lower costs to the Managed Care provider rather than optimal health benefit to the patient. These policies have disrupted many patients’ medication regimens, as they have been required to switch over to medications on the Managed Care preferred drug lists regardless of a patient’s history of unsatisfactory response to a medication. Among the affected classes of drugs are anti-depressants, anti-rejection drugs used in the treatment of organ and tissue transplants, and new anti-retrovirals still under patent and not yet available as a generic.
Atypical anti-psychotics were also among the list of medications initially affected by the shift to Managed Care. The 2012–13 budget restored "prescriber prevails" provisions for atypical anti-psychotics (effective January 1, 2013) in recognition of the significant problems that Medicaid recipients were experiencing in accessing appropriate medication to treat their mental illness. However, repeal of this provision may be included in the 2013-14 Executive Budget, potentially undermining efforts enacted to mitigate issues accessing these medications and jeopardizing the health of people managing their HIV and mental health conditions.
Treatment for HIV is different from treatment from most other illness because each patient’s drug regimen is unique and often difficult to calibrate. Small changes have great effects on individual patients, and doctors must carefully match treatments to patients to minimize side effects and increase adherence. Requiring prior approval or preferred drug lists for these drugs makes it more difficult for beneficiaries to access critically needed medications by increasing bureaucratic barriers.
Many of GMHC’s clients participate in the Medicaid program and take multiple medications to treat their HIV infection, as well as other serious and chronic health conditions. The current Managed Care model presents significant barriers to maintaining their health and well-being. Health care providers are best suited to decide what drugs or drug combinations will improve their patients’ health outcomes. It is shortsighted to allow these decisions to be made by health plan bureaucrats, who have no intimate knowledge of a patient’s health condition or each highly individualized treatment regimen.
To address the aforementioned issues, GMHC recommends the following:
Restore “prescriber prevails” provisions for all drug classes, including anti-rejection, anti-depressant, new and emerging anti-retrovirals, and other drugs used in the treatment of HIV/AIDS.
Uphold patient protections for atypical antipsychotic medications.
Eliminate Managed Care prior approval or preferred drug list requirements for the treatment of HIV/AIDS or Hepatitis C.
Require the Pharmacy and Therapeutics Committee to have representation from licensed medical practitioners (physicians, nurses, pharmacists, etc.) experienced in HIV/AIDS treatment and care to ensure formulary or prescription drug lists are developed with appropriate clinical expertise in representing the needs of people living with the virus.
Require preferred drug lists to consider safety, efficacy and patient outcomes, with cost as a secondary factor, when being developed.