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Medicaid Coverage of Physician-administered Drugs

Many of the high-cost specialty drugs in the pipeline, such as cell and gene therapies, require physician administration. As such, physician-administered drugs (PAD) are expected to be a key driver of Medicaid drug spending in the future. Existing research on the Medicaid prescription drug benefit has primarily focused on drugs obtained through a pharmacy, and little information is publicly available on how state Medicaid programs pay for and manage utilization of PADs.

This session provided background information on how Medicaid policy differs for PADs compared to other drugs dispensed through a pharmacy. MACPAC provided information on some particular challenges related to managing PADs through the medical benefit. Finally, we summarized findings from our analysis on Medicaid utilization and spending on PADs using data from the Transformed Medicaid Statistical Information System.