First Phase of Apple Care Preferred Drug List

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December 29, 2017

By Dan Lessler, MD, Chief Medical Officer, Washington State Health Care Authority

In 2018, HCA will implement a new approach for prescription medications for Apple Health (Medicaid) clients. It is called a single preferred drug list (PDL). While we are making this change at the direction of the Legislature, it is the right thing to do to better serve prescribers, pharmacists, and clients.

A single PDL will provide the same set of medications to Apple Health clients, whether they are in a managed care plan or the Apple Health fee-for-service program.

I travelled around the state earlier this year to hear from providers what their top pain points were when working with HCA. Almost to a person, their top need was simplification around prescription drugs. Currently, providers serving Apple Health patients must check which plan the patient is enrolled in, which drugs that plan prefers, and what the coverage criteria are for that drug.

With a single PDL, providers will know what drugs in each drug category are preferred across all Apple Health clients, and will know the criteria for each (drug, dose, duration and prior authorization requirements).

In addition to administrative simplification, a single PDL will allow HCA as the state purchaser to maximize savings through supplemental rebates.

We are implementing the single PDL in a phased approach, because of the complexity of the systems requiring changes to support the single PDL. Beginning Jan. 1, 2018, 13 drug classes will move to the single PDL. These classes were selected with the support of the Drug Utilization Review Board, and with public input. They are some of the most commonly prescribed and highest cost drugs for the state. We will add more drugs in July.

We have three top priorities for implementing the single PDL:

  • Patient care and access to necessary medications come first. We will be working closely with the Apple Health managed care plans to ensure a smooth transition for Apple Health clients.
  • Patients, prescribers, and pharmacies have easy access to the right information. We appreciate that a single PDL means work for prescribers and pharmacies in the short term. Longer term, Apple Health clients and managed care organization network providers will be better served by one standard PDL.
  • Minimize disruption to patients and providers. With a preferred drug list, drugs prescribed for a specific use must come from the list. For example, not all of the drugs within a specific drug class that are used to treat high blood pressure will be available on the Apple Health preferred drug list (PDL).

When we first implement the PDL, some patients may need to change medications. We are working hard to limit the impact on patients and their providers.

Some drugs will be “grandfathered.” That means patients who are  already on a grandfathered drug when the PDL takes effect will not have to change their medication.

Moving to a single PDL is a major change for our state. We are confident that a single PDL for the Medicaid population will provide savings for the State and make the prescribing process easier for providers and patients.

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