" THE VIRGINIA PREFERRED DRUG LIST"

In the 2003 General Assembly Session, a new rule was added to the coverage for certain Medicaid beneficiaries. A new list of allowable medications will be developed called the "Preferred Drug List" or PDL.

This is how the PDL works -- If your doctor wants to prescribe a medicine for you, she must first look at the PDL. If the medicine she wants is NOT on that list, she must get "prior authorization" from DMAS before you can get that medicine. Depending on the reason for her choice, and the cost of the drug, DMAS could say "yes" or "no, the medicine is too costly; please select another drug."

The medicines on the PDL are supposed to cost the state the same as or less than the average cost of medicine that is effective for the problem your doctor is trying to treat. In order to get a medicine that might cost more, prior authorization is required.

For persons living with HIV/AIDS (PLWH/A's), the antiretroviral drugs will be "exempt" from this process. That means that your doctor can prescribe the antiretroviral(s) of choice, without looking at the list or getting prior authorization.

It is not clear, however, if the other medicines often prescribed for PLWH/A's will be included on the PDL.

VORA is working with the state agency in charge of this program (Department of Medical Assistance Services) to make sure that access to medicines by PLWH/A's is not disrupted by the state's new rules -- intended to save money for the Medicaid program overall.

To read the testimony that VORA presented to DMAS on June 18, 2003, click here.

You can also find more details about the PDL by visiting www.dmas.state.va.us/pharm-home.htm.

To provide your own input to DMAS about the process or the PDL, write to PDLinput@dmas.state.va.us.

To talk to VORA about the program, write to VORA@novam.org.


The Budget Bill Language

Program must generate savings of $9 million GF in FY 2004, and $18 million GF in subsequent fiscal years.
Pharmaceuticals & Therapeutics Committee
June 18, 2003 Meeting

Good morning.
I am Sue Rowland, Director of Public Advocacy for a grassroots consumer group, the Virginia Organizations Responding to AIDS. Called VORA for short, this group is made up of agencies, organizations, and individuals who have an interest in strong public policy that serves to reduce the spread of HIV and to allow for effective treatment and supportive services for persons living with the disease in our state.

Over 15,500 people are living with HIV/AIDS in our state. VORA works to assure that comprehensive prevention and treatment services are available throughout the state, in both rural and urban areas, where federally funded programs seem to be rich in funding, and where the funding is more limited.

We thank you for the opportunity to speak today, and especially thank Jill Hanken, who coordinated the consumer advocates for today's public hearing.

And we'd be remiss for not also thanking the General Assembly for the directive that this committee make recommendations to the Department about the appropriate exclusions for medications used for the treatment of HIV-related conditions. We appreciate that the antiretroviral medications are among those key therapeutic classes of drugs to be excluded from the PDL program according to recent DMAS' presentations. We trust that you all aware that these medications are critical to the health and well being of persons living with this virus (PWA's) -- and that any barriers to these medications, real or perceived, can result in consequences that are potentially life threatening, yet easily avoidable.

DMAS has recently reported that on November 30th of last year, 316 persons were enrolled in the HIV/AIDS Waiver program. (Some additional number of persons living with HIV/AIDS (PWA's) are also Medicaid eligible and may be receiving assistance for treatment services through Medicaid's other programs.) The strict income requirements for adults to qualify for Medicaid and Virginia's strict criteria for assessing nursing home eligibility (a requirement to become enrolled in any waiver program) serves to limit the number of PWA's that can qualify for this program.

However, for the over 300 persons enrolled, the waiver program is critical to achieving any improvement in disease condition because it provides access to skilled physicians and to the medications.

Today, we are asking that as you examine the responsibilities that you hold as members of the PTC, that you consider three issues in particular:
  1. The importance of the PWA (consumer or beneficiary) & provider training & education component of the PDL, particularly as it impacts your decisions;
  2. Using the AIDS Drug Assistance Program Formulary in your consideration of medications other than antiretroviral therapies which are as important to PWA's; and
  3. The processes that will be used to provide you with information on how your decisions may or may not be impacting upon health outcomes of the Medicaid clients included in the program.

Consumer / provider training and education
While the direct responsibility for the training & education rests with the firm that will administer the program, the effectiveness of this component will have a direct impact upon the access to medicines by beneficiaries covered by the new plan. For PWA's, life is commonly complicated by multiple diagnosis (substance abuse, mental illness, hepatitis, and other HIV-related diseases). Of course, PWA's who qualify for these programs also have very low incomes – so that all the challenges of poverty are also at hand.

We already know that when Medicaid clients are shifted from one payment system to another, disruptions occur as clients make mistakes in acting within the new systems. The same kinds of disruptions can be expected in a new program for medications. Even though Antivirals will be excluded from the PDL, other medications commonly used by PWA's may not be. Other medications may not be included, are not exempt, and will require pre-authorization.

AIDS Drug Assistance Program's Formulary
We suggest that when looking at the other classes of medications that are also commonly used to treat HIV and HIV-related conditions the ADAP Formulary be used. "ADAP" is the AIDS Drug Assistance Program, and provides a formulary of medications used for HIV-related illnesses. PWA's who do not qualify for Medicaid and have an income of up to 250% of poverty can qualify for ADAP assistance. An Advisory Committee whose members are appointed by the State Health Commissioner creates the Formulary. That Committee is also charged with selecting medications that are safe and clinically effective, as well as cost effective since the medications on the Formulary are paid for with a combination of state general funds and Ryan White Title II dollars. The funding is limited, and the Advisory Committee's decisions must not result in a growth in the rate of expenditures that would limit the number of eligible PWA's enrolled in the program. The ADAP Advisory Committee is made up of physicians and other clinicians with expertise in HIV treatment along with PWA's. The Formulary should be an appropriate tool for the Pharmacy & Therapeutics Committee to use when considering the other classes of drugs used by PWA's.
Monitoring the Effects of the PDL
The PDL program has grown out of the need to produce savings in the escalating costs of medications in the overall Medicaid program, as such must respond. However, the decisions that will be made by the Committee must also be evaluated in the context of the impacts upon the health status of the impacted beneficiaries. Particularly among people that must rely upon Medicaid programs for assistance in financing their health care services, late or inconsistent treatments due to access barriers are known to lead to more serious and more costly care. Virginia should take the lead in constructing a monitoring program that will assess the impacts of your decisions, assuring the cost of medications is not held in check at the expense of the health of its beneficiaries.

Thank you very much for this opportunity. We look forward to working with you further as you embark upon your tasks.