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Information provided by OMPP.
Effective July 1, 2023, IHCP is announcing alignment of all managed care prescription drug benefit programs with the fee-for-service (FFS) Preferred Drug List (PDL). Effective for claims with dates of service on or after July 1, 2023, all managed care plans will cover both preferred and nonpreferred drugs, maintain the same clinical criteria requirements and use the same format for prior authorization (PA) as the FFS program. Alignment of PA criteria and format for drugs not managed by the PDL will not be included in this process at this time.
The IHCPs’ Statewide Uniform Preferred Drug List (SUPDL) initiative is like those already implemented by surrounding state Medicaid programs. The goal of this initiative is to improve provider and member experience through enhanced and simplified medication access across all IHCP prescription drug benefits without increasing overall prescription drug expenditures. In addition, an aligned pharmacy benefit is consistent with OMPP’s strategic initiative of managed care alignment and optimization.
State Medicaid programs primarily utilize PDLs as a cost-savings measure. If there is more than one manufacturer of a drug in a drug class, the manufacturers may compete to have their drug listed as preferred on a PDL by offering supplemental rebates to the state. The states may award drug(s), with equal or greater efficacy and safety profiles, offering the highest rebates, preferred status. These supplemental rebates reduce net drug expenditures to state Medicaid programs. The remainder of the drugs in the class are considered nonpreferred, requiring medical justification for use over the preferred drugs.
The Office of Medicaid Policy and Planning (OMPP) will direct SUPDL development and maintenance, utilizing the assistance of the FFS pharmacy benefit manager, OptumRx. The Therapeutics Committee will review the SUPDL and corresponding PA. The schedule for review of therapeutic classes, including clinical data submission and rebate bid submission due dates, can be found by selecting the Boards and Committees tab, then Therapeutics Committee on the OptumRx Indiana Medicaid website (accessible from the Pharmacy Services page at in.gov/Medicaid/providers). The Drug Utilization Review (DUR) Board will review SUPDL recommendations from Therapeutics Committee as they have previously for the individual FFS and managed care PDLs. Notices of the DUR Board meetings and agendas are posted on the FSSA website at in.gov/fssa. Click FSSA Calendar on the left side of the page to access the events calendar.
Members with a paid claim prior to July 1, 2023 for a nonpreferred drug, may continue to receive coverage for the drug up to 90 days following SUPDL implementation to allow time to transition to a preferred drug on the SUPDL. Providers are encouraged to submit a PA request, during this time, if continuation of therapy for the nonpreferred drug is medically justified over the preferred.
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