1. Medicaid Coverage of Pharmaceuticals Life Science Tennessee
Trends in Access and Reimbursement
Life Science Tennessee
November 3, 2016
DRAFT

2. Access and Financing Trends in the States
Restrictive prior authorization criteria: States are drafting more selective prior authorization criteria
Step therapy requirements
Demonstration of clinical success in order to remain on the drug
Has led to concerns from CMS (in the case of HCV drugs) and litigation
Drug carve ins: Many states are carving pharmacy into the managed care benefit
Drug effectiveness studies: States share resources of analysis of drug effectiveness or turn to outside bodies
Coverage delays: States/MCOs are taking more time in determining the coverage criteria for new drugs
Medicaid Coverage of Pharmaceuticals: Trends in Access and Reimbursement

3. Potential Solutions to the Access/Financing Client
Supplemental rebates/Unified formulary: Manufacturers offer higher rebates for preferred formulary placement, more favorable prior authorization criteria, and/or unified formulary across MCO/FFS
Expert consultation: Pharmacy and Therapeutic Committees confer with subject matter experts when examining drugs that treat rare diseases
Ombudsmen/commissions: Health care advocate or established commission focuses on issues related to specific population (e.g., rare disease population)
Prescriber prevails: Prescriber may override state’s non-coverage determination if drug is certified for a medically necessary purpose
New drug timeframes: Establish specific timeframes for review of newly approved drugs
Value based purchasing: Drug pricing takes into account effectiveness
Medicaid Coverage of Pharmaceuticals: Trends in Access and Reimbursement

4. Presentation developed by:
Thank You!
Anthony Fiori | Managing Director
Danyel re: how do you know how much $ to put in the rate --
Medicaid Coverage of Pharmaceuticals: Trends in Access and Reimbursement 4