Uncertain Access to Needed Drugs: Challenges for Medicaid Beneficiaries Jack Hoadley, Ph.D. Research Professor Georgetown Health Policy Institute July 27, 2007

2 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

3 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

4 Broward Plan Enrollment, June 2007 Source: July 2007 Florida Medicaid Reform Enrollment Report, AHCA HMOs PSNs

5 Duval Plan Enrollment, June 2007 Source: July 2007 Florida Medicaid Reform Enrollment Report, AHCA HMOs PSNs Shands/ First Coast Advantage 21.86%

6 Did Reform Plans Use Their Flexibility to Limit Drug Benefits?

7 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.

8 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.

9 Drug Benefit Limits, Medicaid Reform HMOs PlanBroward CountyDuval County Amerigroup9 prescriptions per month Buena VistaNo limit Humana$5,350 per year Preferred Medical Plan, Inc.No limit Total Health ChoiceNo limit Vista Health Plan of South FloridaNo limit United Health Care$5,400 per year Wellcare: Health Ease (largest enrollment in Duval) No limit Wellcare: Staywell (largest enrollment in Broward) 9 prescriptions per month NOTE: For plans with limits, higher limits apply to adults with disabilities.

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

11 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.

12 Scope of Drug Lists, Medicaid Reform HMOs PlanBrowardDuval 50 Top Drugs Percentage United HealthCare √√4896% Vista (Buena Vista, Vista Health Plan) √4590% Humana √4488% Wellcare (Health Ease and Staywell) √√4182% Total Health Choice √3978% Amerigroup √3978% Preferred Medical Plan √3774% Florida Medicaid PDL 4896%

13 Drugs Most Often Omitted from Reform Plan Drug Lists DrugDrug Class Number of Plans Not Listing Drug on PDL NexiumGastrointestinal7 LipitorHigh Cholesterol6 SynagisRespiratory syncytial virus6 PrevacidGastrointestinal4 AbilifyAntipsychotic3 ActosDiabetes3 GeodonAntipsychotic3 ZocorHigh Cholesterol3 ZyprexaAntipsychotic3

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

15 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?

16 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?

17 Eduardo’s Drugs Under Reform Drug United Health Care WellcareVistaHumana Total Health Choice Amerigroup Preferred Medical Plan Fluoextine √√√√√√QL Benzotropine √√√√√√ Abilify PA√√ Clonazepam √√√√√√√ Torsemide PA√√√ Omeprazole √√QL√√√ Available, restricted Available, unrestricted NOTE: √ – on the preferred drug list; PA – prior authorization, QL – quantity limit

18 Are Beneficiaries Having Problems with Access to Needed Drugs?

19 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

20 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.”

21 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.