States reported limited oversight of their Medicaid managed care organizations’ (MCO) management of specialty drug categorization and spending. Twenty-four States reported that they were not aware of all the cost management strategies their MCOs implemented to contain specialty drug spending. Because Medicaid MCOs are responsible for the majority of Medicaid prescription drug reimbursement, a lack of cost containment by MCOs can increase long-term Medicaid expenditures, as States base MCO capitated payment rates on costs and utilization from previous years. States also may be limited in their ability to set accurate reimbursement for specialty drugs. The Centers for Medicare and Medicaid Services (CMS) conducts the national average drug acquisition cost (NADAC) survey to collect what pharmacies actually pay for drugs. This is a tool States can use to set accurate reimbursement amounts. However, this survey does not include acquisition cost data from specialty or mail-order pharmacies. As a result, 60 percent of drugs categorized as specialty drugs with Medicaid reimbursement in 2018 did not have NADAC data available.
- Read the Summary: https://go.usa.gov/xAZSe
- Read the Full Report: https://go.usa.gov/xAZSt
