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Some State Medicaid managed care programs have policies that could restrict access to needed medications

Over half (56 percent) of the nearly 19 million people insured by State Medicaid programs were in managed care plans during 2000. Some States allow Medicaid managed care organizations (MCOs) to implement drug prescription policies that could reduce access among certain groups to needed medications, according to a survey that was supported by the Agency for Healthcare Research and Quality (HS09819).

Robert J. Buchanan, Ph.D., of the Texas A&M University System Health Science Center, surveyed the contact person for the Medicaid Drug Rebate Program in each State and the District of Columbia beginning in January 2000. Data collection and verification was completed in July 2001.

The survey uncovered policies that could reduce medication access, such as drug use limits, copayments, restrictive formularies, and restrictions on off-label use. Many Medicaid programs allowed MCOs to limit the number of medications that Medicaid recipients received during 2000. However, in almost all States that allowed MCOs to limit use of medications, these MCOs had to allow exceptions for medical necessity. Many Medicaid programs also allowed MCOs to require copayments for medications from Medicaid recipients during 2000.

Many States did not require MCOs to allow off-label use of prescriptions, with only a few making exceptions to allow off-label use for Medicaid recipients infected with the human immunodeficiency virus (HIV). Since almost half of the drugs used to treat HIV disease are prescribed for off-label indications, this policy may restrict HIV patients' access to needed medications. A number of States did report that off-label use was allowed at the discretion of the MCO. States were about evenly divided between Medicaid programs allowing MCOs to implement open or restrictive drug formularies during 2000. Nearly all Medicaid programs that allowed MCOs to implement restrictive drug formularies required them to cover all HIV-related medications.

See "Medicaid managed care and coverage of prescription medications," by Dr. Buchanan, in the August 2002 American Journal of Public Health 92(8), pp. 1238-1243.

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