Medicaid reimbursable drugs

Until 1991, State Medicaid agencies had the authority to restrict the drugs that Medicaid covers. In 1990, about 22 States had restrictive formularies, which limited reimbursable drugs to a defined list. Another 28 States had open formularies," under which all drugs are reimbursable except for those explicitly identified as ineligible. 

Ford, M., Medicaid Reimbursement for Outpatient Prescription Drugs, Congressional Research Service Report to the U.S. Congress, No. 91-235 EPW (Washington, DC U.S. Government Printing Office, March 7, 1991). 

Soumerai, S., et al., "Effects of Limiting Medicaid Drug Reimbursement Benefits on the Use of Psychotropic Agents and Acute Mental Health Services by Patients with Schizophrenia," N. Engl. ]. Med., 331, 650-655 (1994). 

The medication costs in this study are for branded Lovastatin and generic niacin. For niacin, the cost was taken to be Medicaid s reimbursement for multiple-source drugs. The actual measure was slightly below the average wholesale price but was above the lowest wholesale prices quoted. For Lovastatin, costs were estimated using the 1994 average wholesale price. 

Soumerai SB, McLaughlin TJ, Ross-Degnan D, et al. 1994. Effects of limiting Medicaid drug-reimbursement benefits on the use of psychotropic agents and acute mental health services by patients with schizophrenia. NEnglJ Med 331 650... 

The Health Care Financing Administration (HCFA) establishes the policies that individual State Medicaid programs must adhere to. In the realm of prescription drug reimbursement, rules were established in 1987 for multisource drugs. Upper payment limits based upon estimated... 

For an example, let us consider a drug where the AWP is 60.00. The patient paid 3.00, and the pharmacy will be reimbursed 60.00 less 12%, which equals 52.80 less the 3.00 patient copayment or 49.80 by that state Medicaid agency. In addition, the pharmacy will receive 4.00 as a dispensing fee. 

State Medicaid programs reimburse the pharmacist after a drug is dispensed to a Medicaid enrollee (235). States pay a freed dispensing fee and an amount to cover the cost to the pharmacy of the prescribed drug. The median dispensing fee in 1990 was 4.10 (287). 

Based on data from the TAP and VIP trials, the Food and Drug Administration approved vertepofin PDT to treat AMD. The Centers for Medicare and Medicaid Services initially approved Medicare insurance reimbursement on July 1,2001 for verteporfin PDT to treat predominantly classic CNV associated with AMD. On April 1, 2004, Medicare insurance reimbursement for verteporfin PDT was approved for small (four DAs or less) minimally classic and pure occult CNV lesions associated with AMD that show recent progression. Recent progression was defined as a decrease in visual acuity of five or more letters along with lesion growth (an increase of at least one DA), or the appearance of blood associated with the lesion, within the preceding three months (31). 

Many consumers, in a variety of countries, are unclear why identical drugs from the same manufacturer are cheaper to buy abroad, and are tired of the rhetoric. In the main, the FDA will drive the reimbursement policy through Medicare and Medicaid, while private payers will take their lead from the FDA. With regard to reimbursement in Europe, the same may hold true if the government, consumers and payers line up together and challenge the major manufacturers of biopharmaceuticals. If this example can be taken to its final conclusion, it becomes clear that healthcare, business and poHtics - from a global perspective - have become a uniform planetary phenomenon. 

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