Kelly Vyzral, Director of Government Affairs
Some major changes occurred in the Medicaid pharmacy program due to passage of HB 153, the budget bill. As we notified you previously, the Medicaid pharmacy benefit is being carved back into managed care. This will take place on October 1, 2011. The Medicaid managed care plans that currently administer the medical benefit will take over the pharmacy benefit when it is carved in. They are: Amerigroup, Buckeye, CareSource,
Molina, Paramount Advantage, United Community Plan, and WellCare.
The State of Ohio is going to re-procure the Medicaid managed care program and will be requesting proposals at the end of July/beginning of August. Any plan selected will begin on July 1, 2012.
Unfortunately, the Medicaid dispensing fee remains at $1.80. The Governor was successful at inserting it in the budget. We worked very hard to have the dispensing fee raised, but due to the $8 billion budgetary hole that Ohio was trying to fill, we were unsuccessful. Because the pharmacy benefit is going back to managed care on October 1, 2011, the population that this $1.80 dispensing fee affects is the population not included in managed care. This includes dual eligibles (Medicare/Medicaid), disabled children, institutionalized individuals, individuals in waiver programs, and individuals who have a spend-down.
Dispensing Fee.
We do intend to pursue legislation to increase the dispensing fee and require more frequent updates of the formulary pricing. It is notable that CMS hasn’t yet approved the Ohio State Plan Amendment (SPA), that dropped the dispensing fee to $1.80, that was filed over a year ago. We are also actively working on getting CMS to disapprove the SPA. If you haven’t already contacted your state representative and state senator, please do so and let them know how damaging this rock bottom dispensing fee is to your pharmacy.
New Restrictions on Prior Approval.
The budget bill placed restrictions on Medicaid managed care plans in regards to antidepressants and antipsychotics. The law prohibits health insuring corporations (HICs) participating in Medicaid managed care from imposing prior authorization requirements for mental health drugs that are antidepressants or antipsychotics, with the following conditions: 1) the drugs must be in standard tablet or capsule form, but allows antipsychotics to also be in a long-acting injectable form; and 2) the drugs must be prescribed by a psychiatrist credentialed by the HICs or a psychiatrist practicing at a certified community mental health agency.
The law also prohibits HICs participating in Medicaid managed care from imposing prior authorization requirements if the recipient was being treated with antidepressants or antipsychotics or the drug was prescribed by any other health professional who was treating a Medicaid recipient immediately before Medicaid managed care resumes coverage of prescription drugs, but only for a 120-day period. It also requires that Medicaid managed care organizations maintain coverage for all drugs for a 90-day period without using drug utilization or management techniques that are more stringent for a Medicaid recipient than before the recipient’s coverage is transferred to the managed care plan.
This bill was introduced by Rep. Michael Stinziano and it would increase the penalties for robbery, burglary, and breaking and entering when the offenses occur in or in the vicinity of a pharmacy.
The legislation increases the penalties in the following areas:
•Robbery and burglary are both changed from second to first degree felonies.
•Breaking and entering is changed from fifth degree to fourth degree felony.
The introduction of this bill is greatly appreciated. With the crackdown on pill mills and dispensing physicians, the next logical place criminals will look for drugs will be the pharmacy. Recently we have seen a rash of pharmacy robberies across the country with deadly results.
Introduced by Sen. Gillmor and Sen. Oelslager, SB 194 would update Ohio law in two ways:
•Ensures equity for patient out-of-pocket expenses between oral chemotherapy and IV chemotherapy drugs.
•Prohibits insurance companies from requiring a patient to directly receive their chemotherapy meds from a retail or mail order pharmacy.
OPA has been working closely as part of a coalition on the drafting and introduction of this legislation. While Sen. Gillmor was recently appointed to the Ohio Industrial Commission and has left the Senate, the other sponsor, Sen. Oelslager, is very knowledgeable about the issue and is the chairman of the Senate Health Committee where the bill will likely end up.
If you have any questions about information in the article, please contact Kelly Vyzral at 614.389.3236 or kvyzral@ohiopharmacists.org.