Uncertain Access to Needed Drugs: Challenges for Medicaid Beneficiaries

Jack Hoadley, Ph.D.

Research Professor

Georgetown Health Policy Institute

July 27, 2007

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Our Study Methods for this Brief

Analysis of benefit offerings and preferred drug lists for reform HMOs serving Broward and Duval Counties.

Eight focus groups were conducted in Broward and Duval counties in summer 2006 and Jan/Feb 2007 with Medicaid beneficiaries

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Who is Affected by the Medicaid Pilots?

Total enrollment as of July 2007 is 175,424 Broward enrollment: 106,448 Duval enrollment: 68,976

84% are children and parents 15% are people with disabilities receiving

SSI but not Medicare

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Other HMOs 5.9%

Pediatric Associates

8.9%

SFCCN 6.3%

Other PSNs 9.6%

Staywell 24.8%

Healthease 13.5%

Amerigroup 10.0%

Humana 9.5%

United Healthcare

5.7%

BuenaVista5.9%

Broward Plan Enrollment, June 2007

Source: July 2007 Florida Medicaid Reform Enrollment Report, AHCA

HMOs

PSNs

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Duval Plan Enrollment, June 2007

United Healthcare

11.2%

Access Health Solutions, 9.3%

Healthease, 51.9%

CMS, 1.8%

Staywell3.8%

Source: July 2007 Florida Medicaid Reform Enrollment Report, AHCA

HMOs

PSNs

Shands/ First Coast

Advantage 21.86%

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Did Reform Plans Use Their Flexibility to Limit Drug Benefits?

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Rules for Benefit Variation

Plans can offer different benefits, allowing consumers to choose.

Can limit drug benefit subject to a sufficiency test. Coverage must meet the needs of 98.5% of beneficiaries. Non-disabled adults: 9 prescriptions per month, or $5,321

annually. Adults with disabilities: 16 prescriptions per month, or

$24,472 annually.

Plans may adopt a preferred drug list. Beneficiaries can obtain drugs not on the list with

prior authorization.

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Drug Benefit Limits, Medicaid Reform HMOs

Broward County: 4 of 9 HMOs (with 50% of reform enrollment) adopted limits.

Duval County: 2 of 3 HMOs (with 15% of reform enrollment) adopted limits.

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Drug Benefit Limits, Medicaid Reform HMOsPlan Broward County Duval County

Amerigroup 9 prescriptions per month

Buena Vista No limit

Humana $5,350 per year

Preferred Medical Plan, Inc. No limit

Total Health Choice No limit

Vista Health Plan of South Florida No limit

United Health Care $5,400 per year $5,400 per year

Wellcare: Health Ease (largest enrollment in Duval)

No limit No limit

Wellcare: Staywell (largest enrollment in Broward)

9 prescriptions per month

9 prescriptions per month

NOTE: For plans with limits, higher limits apply to adults with disabilities.

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Is the Drug Coverage Offered by Reform Plans as Good as That Provided by the State?

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Analytical Approach

50 commonly prescribed drugs. 30 with highest number of prescriptions 30 with highest total costs

Reviewed plan preferred drug lists, compared to state Medicaid drug list.

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Scope of Drug Lists, Medicaid Reform HMOs

Plan Broward Duval50 Top Drugs

Percentage

United HealthCare √ √ 48 96%

Vista (Buena Vista,

Vista Health Plan)√ 45 90%

Humana √ 44 88%

Wellcare (Health Ease and Staywell)

√ √ 41 82%

Total Health Choice √ 39 78%

Amerigroup √ 39 78%

Preferred Medical Plan

√ 37 74%

Florida Medicaid PDL 48 96%

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Drugs Most Often Omitted from Reform Plan Drug Lists

Drug Drug ClassNumber of Plans Not Listing Drug on PDL

Nexium Gastrointestinal 7

Lipitor High Cholesterol 6

Synagis Respiratory syncytial virus 6

Prevacid Gastrointestinal 4

Abilify Antipsychotic 3

Actos Diabetes 3

Geodon Antipsychotic 3

Zocor High Cholesterol 3

Zyprexa Antipsychotic 3

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Can Beneficiaries Get Good Information to Select a Plan That Fits Their Drug Needs?

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How Do Beneficiaries Learn About Drug Coverage?

What they most want to know: Are my particular drugs covered? Information on drug lists not available from

Choice Counselors. Challenging to get information from plans.

In focus groups, beneficiaries had trouble understanding key information. What plan is best for a person who needs a lot of

drugs?

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What Happens When a Beneficiary Looks at Plans?

Eduardo is a Medicaid beneficiary. Takes 6 drugs monthly Wants to choose a reform plan

Assume he finds the drug lists for all plans. Which plan provides the best coverage for his

drugs?

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Eduardo’s Drugs Under Reform

Drug

United Health Care Wellcare Vista Humana

Total Health Choice Amerigroup

Preferred Medical

Plan

Fluoextine √ √ √ √ √ √ QL

Benzotropine √ √ √ √ √ √

Abilify PA √ √

Clonazepam √ √ √ √ √ √ √

Torsemide PA √ √ √

Omeprazole √ √ QL √ √ √ QL

Available, restricted 4 3 3 5 6 5 3

Available, unrestricted 4 3 5 6 6 5 5

NOTE: √ – on the preferred drug list; PA – prior authorization, QL – quantity limit

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Are Beneficiaries Having Problems with Access to

Needed Drugs?

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Focus Group Participants Reported Problems

Problems getting medications after joining a plan or during transition.

Need to get doctor’s appointment quickly to change prescription.

Problems especially a concern for beneficiaries with disabilities.

Doctors may help with requesting exceptions or providing samples

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Physicians Surveyed Also Reported Concerns

As reported in the brief released in May: Benefit limits or formularies often impeded

ability to provide needed treatments. Plans have “very different criteria for prior

authorization of injectible medications” Case manager having “a rough time getting

drugs, therapies, referrals, etc.”

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Conclusions

Drug benefits for reform HMOs are generally more restrictive than the state benefit. Half of reform HMOs use flexibility to limit drug

benefits. Virtually all HMOs include fewer common drugs

on preferred drug lists than state PDL. Information needed to make an informed

choice of plans is hard to get. Beneficiaries are reporting problems getting

access to drugs.