Pennsylvania’s Medicaid program will have a single statewide Preferred Drug List (PDL) effective January 1, 2020.
The statewide PDL was developed by the Department of Human Services (DHS) Pharmacy and Therapeutics (P&T) Committee. DHS officials report that requiring the Medicaid managed care plans to use a single medication formulary will result in substantial cost savings for the Medicaid program and improve consistency for providers and recipients. Each individual Medicaid managed care plan currently maintains its own list of preferred or non-preferred medications (formulary), and its own corresponding prior authorization guidelines. Under the statewide PDL, all Medicaid managed care plans responsible for providing medicines to their members—i.e., HealthChoices plans Community HealthChoices (CHC) plans—and MA Fee-for-Service (FFS) will use the same list of preferred medications and the same prior authorization guidelines.
The DHS Pharmacy Director reported at a public meeting in late October that 149,741 consumers would be impacted by the transition, meaning they would need to change medications or get prior authorization to continue taking their current medication. Of those, about 39,000 would have more than one medication impacted. Both FFS MA and the Medicaid managed care plans are scheduled to mail letters to impacted consumers by November 1, sixty (60) days prior to the effective date.
Medicaid consumers who get a letter about the new PDL should talk to their doctors about the preferred medication listed on that letter. They will need prior authorization to have their current medication covered once the new PDL goes into effect in January. The Medicaid managed care plans are required to decide prior authorization requests within 24 hours. Providers should contact the MCOs directly for information about submitting prior authorizaton requests for consumers enrolled in managedcare. Providers seeking information about prior authorization reqeusts for consumers in FFS should refer to DHS' pharmacy prior authorization general requirements and Prior Authorization Clinical Guidelines.
Any Medicaid consumer who has a script denied at the pharmacy because the medication they have been taking now requires prior authorization can request a 15-day emergency supply. Emergency supplies are reimbursed by the managed care plan but provided at the discretion of the pharmacist.