Medicaid Waiver Rejection Signals Win for Patient Access

June 29, 2018

Massachusetts Medicaid patients are breathing a collective sigh of relief.

Federal officials announced this week that Massachusetts will not be allowed to restrict which drugs it covers for Medicaid beneficiaries.  The decision came in response to a 2017 request by the state to the Centers for Medicare and Medicaid Services. Massachusetts Secretary of Health and Human Services Marylou Sudders asked for permission to exclude drugs the state didn’t view as effective and to eliminate coverage for as many as 30 undisclosed medications with high price tags.

This week federal officials explained that moving forward with the proposal would cost the state in a big way: Massachusetts would have to relinquish rebates provided by the Medicaid Drug Rebate Program.  The rebate program covers roughly 99 percent of drugs provided through the MassHealth Medicaid program.

Governor Charlie Baker’s administration had envisioned a formulary as a tool for negotiating drug prices.  But patients recognized its potential to limit access to vital medication.  Advocates spoke out after Massachusetts’ initial request, noting that a range of treatment options are necessary to accommodate individual patients’ responsiveness, side effects or drug-to-drug interactions.  By covering just one drug in some classes, the move would also have restricted patients who need to switch medications after their original treatment begins to lose efficacy.

Relieved patient advocates are praising the Centers for Medicare and Medicaid Services’ decision.  Massachusetts advocacy group Health Care for All emphasized MassHealth’s role in “protecting the health of vulnerable people” and issued a statement of support for the decision.

Meanwhile, Washington, DC-based rheumatologist and advocate Angus Worthing, MD, tweeted “Great news from Massachusetts – access to medicines in Medicaid won’t be restricted.” Dr. Worthing had expressed concern about the proposal’s impact on patient access during the 2018 Institute for Patient Access NationalPolicy & Advocacy Summit on Biologics and Biosimilars.

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