Implementation of New Medicaid Pharmacy Benefits Policy Impacts Access to Contraception

We are pleased to offer our readers a guest blogger today!

President & CEO of Family Planning Advocates, M. Tracey Brooks, explains how the implementation of Medicaid Redesign Team proposal #11, which bundles pharmacy benefits into Medicaid Managed Care, has affected access to certain contraceptives.  Here is Brooks’ entry.

On October 1, 2011, the NYS Department of Health (DOH) implemented Medicaid Redesign Team (MRT) Proposal #11, a carve-in of prescription drug benefits into Medicaid Managed Care (MMC) plans.  Family Planning Advocates of New York State (FPA), which represents the state’s family planning provider network, has been closely monitoring the impact of this proposal on patients and family planning providers.  Since its implementation, women’s access to a broad range of contraceptive methods has been significantly restricted, and providers have faced new administrative challenges.

Prior to MRT Proposal #11, the state supported and women experienced unrestricted access to all FDA-approved methods of contraception under Medicaid fee-for-service.  Based on a preliminary review of prescription drug formularies and anecdotal information from our providers, FPA has found that several MMC plans offer no coverage of brand name contraceptives that lack a suitable generic, such as the NuvaRing, Ortho Evra (the patch) and Ortho Tri-Cyclen Lo.  Access to these methods are important because they have unique properties (i.e. longer acting or have a lower dose of hormones thus fewer side effects) that increase the likelihood of consistent contraception use, resulting in fewer unintended pregnancies and long-term cost savings for the state and MMC plans.

Additionally, many providers are struggling with onerous prior approvals of non-formulary contraceptive methods that sometimes deny patients access to a method they have successfully used in the past.  For example, at least one MMC plan requires patients to have tried two other forms of contraception before approval of a non-formulary method.  Following a “failed first” policy does not make sense given that the likely indicator of failure is an unintended pregnancy.

FPA is working with the Department of Health to remedy these challenges that patients and providers are experiencing under MRT Proposal #11.

-Jaime Venditti, 2/24/12