DEPARTMENT OF
PUBLIC WELFAREMedical Assistance Pharmacy Benefit Package Change [41 Pa.B. 6455]
[Saturday, December 3, 2011]The Department of Public Welfare (Department), under the authority of section 443.6(g) of the Public Welfare Code (Code) (62 P. S. § 443.6(g)), as amended by the act of June 30, 2011 (P. L. 89, No. 22), announces a benefit package change for pharmacy services for adult Medical Assistance (MA) recipients 21 years of age and older, effective January 3, 2012.
Background
The MA Program provides a continuum of physical and behavioral health services, including long-term care, inpatient hospital, pharmacy and outpatient services to approximately 2.2 million Pennsylvanians.
States across the country, including the Commonwealth, are struggling to maintain their Medicaid programs as state revenues continue to lag, failing to keep pace with ever-increasing caseloads and health care costs. While the caseload of persons determined eligible for the MA Program in this Commonwealth continues to grow in State Fiscal Year (SFY) 2011-2012, the General Fund Budget is 4.1% less than SFY 2010-2011 amounts, to near SFY 2008-2009 levels.
Since 2005, the Department has implemented a series of initiatives in the MA Program designed to provide cost effective pharmacy services while enhancing quality, addressing health and safety concerns, and improving administrative efficiencies. Initiatives included implementation of a payment methodology more consistent with other public and commercial third party payers in this Commonwealth; implementation and expansion of a Preferred Drug List; expansion of utilization management programs including quantity limits, clinical prior authorizations, early refill and appropriate age edits; increased generic utilization; maximization of Federal and supplemental rebates; selective contracting and negotiating payments with specialty pharmacies for costly specialty drugs; automated prior authorization; and a comprehensive Retrospective Drug Use Review program for provider educational interventions. These sophisticated, industry-standard, pharmacy management tools enabled the Department to realize significant cost savings, minimize the per-member per-month increase in pharmacy expenditures and increase quality of care, without compromising access or imposing overly burdensome requirements on providers.
Despite the significant cost savings the Department has realized and the Department's plans to continue to refine these pharmacy strategies, General Fund revenue collections continue to fall below estimates and the cost of medications continues to increase. The Department closely evaluated the utilization of and payment for pharmacy services to identify additional cost containment initiatives, including how services could be limited with minimal impact to the health care needs of MA recipients. Based on MA Program utilization and claims data from SFY 2009-2010, the most recent year for which complete data is available, approximately 89% of categorically needy adult MA recipients received fewer than seven prescriptions per month. Approximately 701,410 categorically needy adult MA recipients received on average at least 1 prescription drug per month during SFY 2009-2010. Of those MA recipients, 75,850 or 11% received on average 7 or more prescriptions per month. By limiting the pharmacy benefit package for adult MA recipients, the Department will realize significant cost savings with minimal impact to MA recipients.
Pharmacy Benefit Change
Effective January 3, 2012, adult MA recipients 21 years of age and older will be eligible for six prescriptions for drugs per calendar month.
The pharmacy benefit package change does not apply to MA recipients who are under 21 years of age, pregnant or reside in a nursing facility, in an intermediate care facility (ICF/MR), or in an intermediate care facility for persons with other related conditions (ICF/ORC).
Consistent with the Department's goal in past cost containment initiatives, to avoid a detrimental impact on the health care needs of the MA population, the Department will grant exceptions to the pharmacy benefit package limit when one of the following criteria is met:
1. The Department determines the recipient has a serious chronic systemic illness or other serious health condition and denial of the exception will jeopardize the life of the recipient.
2. The Department determines the recipient has a serious chronic systemic illness or other serious health condition and denial of the exception will result in the rapid, serious deterioration of the health of the recipient.
3. The Department determines that granting a specific exception is a cost effective alternative for the MA Program.
4. The Department determines that granting an exception is necessary to comply with Federal law.
The Department developed an exceptions process for those recipients who may need more than six prescriptions in a calendar month to ensure that recipients maintain access to critically necessary medications. The exceptions process includes an automated approval at the pharmacy point-of-sale for certain conditions, diagnoses and drug classes.
The Department will provide detailed instructions to providers regarding the pharmacy benefit package change by means of an MA Bulletin and updated Pharmacy Handbook pages. This will include instructions for submitting a request for an exception to the benefit limit.
MA managed care organizations (MCOs) have the option to impose the same or lesser limits for the aforementioned pharmacy services. If an MA MCO imposes the same or lesser limits, the MA MCO will issue individual notice to its members at least 30 days in advance of the change and will notify network providers, according to the MCO individual provider agreements, in advance of the change.
Fiscal Impact
This change is anticipated to result in savings of $31.827 million ($14.300 million in State funds) in the MA Program in Fiscal Year (FY) 2011-2012, and annualized savings of $62.826 million ($28.600 in State funds) in FY 2012-2013.
Public Comment
Interested persons are invited to submit written comments regarding this notice to the Department of Public Welfare, Office of Medical Assistance Programs, c/o Regulations Coordinator, Room 515, Health and Welfare Building, Harrisburg, PA 17120. Comments received within 30 days will be reviewed and considered for any subsequent revision of the pharmacy benefit package.
Persons with a disability who require an auxiliary aid or service may submit comments using the Pennsylvania AT&T Relay Service at (800) 654-5984 (TDD users) or (800) 654-5988 (voice users).
GARY D. ALEXANDER,
SecretaryFiscal Note: 14-NOT-734. No fiscal impact; (8) recommends adoption.
[Pa.B. Doc. No. 11-2065. Filed for public inspection December 2, 2011, 9:00 a.m.]
