Managed care plans in Ohio are facing new challenges with a prescription drug benefit "carve-out" in the state's Medicaid program.
In a carve-out, the state contracts directly with a pharmacy benefit manager. State Medicaid agencies generally favor carve-outs for the convenience of dealing with just one contractor.
According to HealthLeaders-InterStudy's "Ohio, Kentucky & Indiana Health Plan Analysis," health plans and state officials haven't compiled cost and use data regarding services since the carve-out was implemented on Feb. 1. Officials say that reports of care disruptions and other effects do not bode well for the program and will likely prompt procedural changes in the coming months.
Prior to the passage of federal healthcare reform, carve-outs had an economic advantage in the greater rebates that states could capture from drug manufacturers. However, health reform legislation included drug rebate equalization measures that will allow managed care organizations to access the same rebates provided through state Medicaid fee-for-service purchasing programs for prescription drugs.
"With the restoration of rebate parity between managed care and fee-for-service populations, federal reforms will likely also encourage recently carved-out Medicaid drug benefits in Ohio to carve back in," said HealthLeaders-InterStudy analyst Rick Byrne. "Should a carve-back-in occur, managed care organizations will likely use a single formulary and a single set of utilization-management restrictions."
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