Category Archives: Massachusetts

Hello readers! Today’s post focuses on a topic we’ve touched on a few times in the past – Medicaid drug formularies.

Back in December 2021, the state of Oregon released a draft Medicaid waiver proposal that caught the attention of many stakeholders. In the draft proposal, Oregon stated that it was considering asking CMS for approval to a) adopt a commercial-style closed drug formulary and b) exclude from Medicaid coverage certain drugs approved via the accelerated approval pathway “with limited or inadequate evidence of clinical efficacy.” Oregon proposed to “use its own rigorous review process to determine coverage of new drugs and to prioritize patient access to clinically proven,… More

Earlier this year, we wrote about a lawsuit involving the 340B drug pricing program.  We sometimes write about the 340B program because  it is integrally linked to the Medicaid prescription drug rebate program.  So today, we wanted to call attention to a proposed regulation issued by the Massachusetts Medicaid program (which is called “MassHealth”) that shows that link clearly.

Section 1927 of the Social Security Act requires pharmaceutical manufacturers to provide a rebate to state Medicaid plans if they want to have their drugs covered by Medicaid. … More

One of the things that gets drummed into your head working with Medicaid is this:  Medicaid is a payer of last resort.  Medicaid can only pay for a health care service when there is no other payer available.  If a Medicaid beneficiary has virtually any other source of health insurance coverage, that coverage pays first.

This requirement is set forth in the basic rules of the Medicaid program;… More

On April 11, 2019, the Massachusetts House Committee on Ways and Means released its FY 2020 budget (H.3800).  The legislation includes provisions authorizing MassHealth (the Massachusetts Medicaid program) to negotiate supplemental rebates directly with drug manufacturers, and provides for further proceedings before the Health Policy Commission for manufacturers refusing to negotiate supplemental rebates at levels satisfactory to the Commonwealth. These provisions represent amendments to a MassHealth drug pricing proposal included in Governor Baker’s FY 2020 filing in January.… More