Medicaid Health Plan Pharmacy Benefit
Update - Proposed Pharmacy Carve-Out Policy
This is an update to Proposed Pharmacy Carve-Out Policy (1936-Pharmacy) issued on September 30, 2019: Medicaid Health Plan Pharmacy Drug Coverage Transition. This policy proposed that Managed Medicaid outpatient pharmacy drug coverage would fully transition to Fee-for-Service (FFS) Medicaid. After careful consideration, the proposed pharmacy transition is not moving forward. As recommended in the Governor’s Executive Budget, the Department will instead be implementing a single Medicaid Preferred Drug List (PDL). The single PDL will maximize drug manufacturer rebates to generate additional budgetary savings. In an effort to ensure the financial sustainability of Michigan’s independent pharmacies, the Department has also proposed raising the Medicaid Health Plan dispensing fee for independent pharmacies to $3.
The Department is preparing a proposed policy for the Single PDL which, in accordance with existing procedure, will include an opportunity for public comment.
As a reminder, Fee-For-Service Medicaid pharmacy coverage questions can be directed to MDHHSPharmacyServices@michigan.gov. Medicaid Health Plan Common Formulary pharmacy coverage questions can be directed to MDHHSCommonFormulary@michigan.gov.
This webpage is designed to provide easy access for members and providers looking for information on the drugs and supplies covered by Michigan Medicaid Health Plans.
All plans must at a minimum cover the drugs listed on the Medicaid Health Plan Common Formulary.
|FOR PROVIDERS AND PRESCRIBERS ONLY|
|Prior Authorization (PA)||Step Therapy|
The Prior Authorization criteria for drugs indicated on the Medicaid Health Plan Common Formulary as requiring PA is below:
A standard prior authorization form, FIS 2288, was created by the Michigan Department of Insurance and Financial Services (DIFS) to simplify the process of requesting prior authorization for prescription drugs. This form or a prior authorization used by a health plan may be used.
The Step Therapy criteria for drugs indicated on the Medicaid Health Plan Common Formulary as requiring ST is below:
Scroll down for health plan specific information.
MEDICAID HEALTH PLANS
Plans may choose to include additional drugs that are not on the Medicaid Health Plan Common Formulary in their own drug formularies. In addition, plans may enforce drug utilization management policies such as quantity limits, age and gender edits, prior authorization criteria and step therapies that are less restrictive than the coverage parameters of the Medicaid Health Plan Common Formulary. Click on the health plans below for more information about their formularies and pharmacy related contact information.
Current beneficiaries can find out which health plan they are enrolled in by calling the Beneficiairy Help Line at 800-642-3195 (TTY 866-501-5656) or by logging in to their myHealth Portal account online at www.michigan.gov/myhealthportal.
For more information on the drug benefit for people not enrolled in a health plan (Fee-for-Service Medicaid) visit https://michigan.magellanrx.com .
For more general information on Michigan Medicaid Health Plans, visit www.michigan.gov/managedcare.
STAKEHOLDER MEETINGS AND COMMENT PERIOD
The next Michigan Medicaid Health Plan Common Formulary public comment period will be announced here.