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Comparison of Medicaid Drug Coverage to Medicare Part D and Commercial Plans

Medicaid agencies have stated that they have limited tools to manage drug utilization compared to other payers and would like to adopt commercial-style tools. To determine whether state Medicaid programs are at a disadvantage in managing utilization compared to other payers, MACPAC contracted with IMPAQ International to compare Medicaid drug coverage and utilization management tools with Medicare Part D and commercial payers.

This presentation summarizes the first phase of this project, which compares coverage and restrictions for selected drug classes under state Medicaid preferred drug lists and Medicaid managed care organizations’ formularies compared to other payers. The second phase of this project, to be completed in the spring of 2019, will link the formulary coverage from the first phase to actual utilization to determine what, if any, is the practical effect of coverage and utilization management tools across payers on utilization, spending, and access.