Medicaid Health Plans Transitioning to Preferred Drug List (PDL)

August 5, 2020

From Priority Health:

The Michigan Department of Health and Human Services (MDHHS) has made changes to the list of drugs that all Medicaid Health Plans (MHPs) must cover. Effective for dates of service on or after Oct. 1, 2020, MDHHS will require MHPs, like Priority Health’s Medicaid program, to follow the Michigan Preferred Drug List (PDL).

 

Background

The PDL is a subsection of the Medicaid prescription drug formulary and is already used by Fee For Service (FFS) Medicaid. You may already be familiar with the PDL if you care for patients covered under Michigan’s FFS Medicaid program. Drugs included on the PDL are selected by Michigan’s FFS Medicaid program to maximize federal rebates. The PDL is organized by drug class, with each drug class being further divided into preferred and non-preferred medications. The goal of the PDL is for Medicaid beneficiaries and prescribers to use the preferred agents in each class. Not all drug classes are included on the PDL.

Since 2016, MHPs (like Priority Health’s Medicaid program) have administered prescription drug programs according to the Michigan Medicaid Common Formulary. The common formulary workgroup will continue to manage drug classes not included on the PDL. For every drug class included in the PDL, MHPs will align with FFS coverage.

 

What does this mean for members of Priority Health’s Medicaid program?

Prior to Oct. 1, 2020, members who are taking a drug that is non-preferred on the PDL list will need to work with their provider to switch to a covered drug or obtain prior authorization to continue receiving the non-preferred drug. Members who are taking a drug that is preferred on the PDL but requires prior authorization may need to work with their prescriber to obtain a new prior authorization.

We’ll send letters to all impacted members with information about the change and the steps they need to take prior to Oct. 1, 2020.

 

What action do you need to take?

You’ll need to work with your Priority Health Medicaid patients who are taking a PDL non-preferred drug, to switch them to a preferred drug or obtain prior authorization to continue the non-preferred drug.

All in-network prescribers with a member impacted by this change will receive a letter outlining the change and steps that need to be taken prior to Oct. 1, 2020.

Additional resources

   

Remember, the PDL will not be fully implemented for MHPs until October 1, 2020. Until then, PDL coverage reflected in the above links only applies to FFS Medicaid. MHPs, including Priority Health’s Medicaid program, will continue to adhere to Medicaid Common Formulary criteria through September 30, 2020.