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Medicaid Reform: Oversight to Ensure Beneficiaries Receive Needed Prescription Drugs Can Be Improved; Information Difficult for Beneficiaries to Locate and Compare, Report No. 08-55, September 2008
 
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  • Medicaid Reform capitated health plans have more flexibility in developing their preferred drug lists than do traditional Medicaid plans.  Although the Agency for Health Care Administration expects plan beneficiaries to have access to the same drugs that would be available to them under traditional Medicaid fee-for-service, it relies on plans’ assurances that they will provide the drugs needed by their beneficiaries.  While the agency has some processes to identify problems beneficiaries experience related to receiving drugs, oversight can be improved.  Our analyses showed that Reform capitated plans’ preferred drug lists do not contain all of the drugs or therapeutic classes of drugs available through Medicaid fee-for-service.  While not listing a drug does not necessarily mean the plan will not cover the drug, beneficiaries may have to go through additional steps such as obtaining prior authorization or step therapy before they can receive the drug. 
  • Although obtaining information about prescription drug coverage is important to many Medicaid beneficiaries, it is difficult for them to locate and compare Reform plans’ drug offerings and prior authorization requirements.  To address this issue, the agency has established a special needs unit to help beneficiaries determine which plans cover the drugs they need.  In addition, the agency is developing an electronic tool that choice counselors can use to help beneficiaries compare prescription drug coverage among the plans.

Which Government Program Summaries contain related information?

Medicaid Health Care Services
Agency for Health Care Administration

What other OPPAGA-related materials are available?

  • Report No. 09-29 Medicaid Reform: Legislature Should Delay Expansion Until More Information Is Available to Evaluate Success,published in June 2009.
  • Report No. 08-64 Medicaid Reform:  Reform Provider Network Requirements Same as Traditional Medicaid; Improvements Needed to Ensure Beneficiaries Have Access to Specialty Providers, published in November 2008.
  • Report No. 08-54 Medicaid Reform: Risk-Adjusted Rates Used to Pay Medicaid Reform Health Plans Could Be Used to Pay All Medicaid Capitated Plans, published in September 2008.
  • Report No. 08-46 Medicaid Reform: Choice Counseling Goal Met, But Some Beneficiaries Experience Difficulties Selecting a Health Plan That Best Meets Their Needs, published in July 2008.
  • Report No. 08-45 Medicaid Reform: Beneficiaries Earn Enhanced Benefits Credits But Spend Only a Small Proportion, published in July 2008.
  • Report No. 08-40 Medicaid Reform: Two-Thirds of the Initial Pilot Counties’ Beneficiaries Are Enrolled in Reform Plans, published in June 2008.
  • Report No. 08-38 Medicaid Reform: More Managed Care Options Available; Differences Limited by Federal and State Requirements, published in June 2008.
  • Report No. 08-37 Medicaid Reform: Few Beneficiaries Have Participated in the Opt-Out Program, published in June 2008.

Copies of this report in print or alternate accessible format may be obtained by telephone (850/488-0021), by FAX (850/487-9213), in person, or by mail (OPPAGA Report Production, Claude Pepper Building, Room 312, 111 W. Madison St., Tallahassee, FL 32399-1475).
e-mail address: oppaga@oppaga.fl.gov


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