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Strengthening Evidence under Medicaid Drug Coverage

Chapter 3 of the report focuses on the coverage of drugs with limited evidence of clinical benefit in the Medicaid program. The recommendations put forward in this chapter aim to provide states with the flexibility to align with a Medicare decision to link coverage with participation in clinical trials or comparative studies, which would help strengthen evidence of a drug’s effectiveness.

The chapter highlights that while Medicaid drug spending is growing, it is increasingly driven by high-cost specialty drugs. States have expressed concern about paying high prices for drugs approved through the accelerated approval pathway. The Commission recommends that Congress amend sections of the Social Security Act to allow states to exclude or restrict coverage of outpatient drugs based on coverage with evidence development requirements implemented under a Medicare national coverage determination.

From: March 2023 Report to Congress on Medicaid and CHIP