formerly Medicaid 101
Federal law provides a level of flexibility for each state to administer their Medicaid programs. This segment provides an overview of the federal provisions that guide states, as well as how states implement those flexibilities when managing their pharmacy benefits.
Most Medicaid recipients receive their healthcare services through contracted Medicaid Managed Care plans. This segment will compare the differences between the Medicaid Fee-for-Service and Medicaid Managed Care plan healthcare delivery models. It will also focus on how pharmaceuticals are managed within the Managed Medicaid model.
Many states employ a pharmacy benefit manager (PBM) to administer functions such as fiscal agent, claims processor, and supplemental rebate negotiator. This segment will identify the PBMs that focus on Medicaid services, explain how they approach their contracted responsibilities for states, and identify important manufacturer actions in each process.
State Medicaid coverage decisions are based on two primary components – clinical efficacy and financial impact. As states evaluate the cost of drugs differently than how a manufacturer evaluates their net revenue of that drug, this segment will review the components a manufacturer needs to be cognizant of when working and negotiating with Medicaid Fee-For-Service programs as it relates to a drug’s financial impact. Topics to be discussed include Medicaid Federal Rebate obligation, Supplemental Rebate opportunities, Unit Rebate Offset Amounts, and Net Costs.