October 3, 2007

Medicaid Policies for Covering Emergency Contraception

On August 24, 2006, the FDA approved that EC could be sold behind-the-counter to women age 18 and older. Women under 18 are still required to get a prescription. According to the National Health Law Program, “this dual-label classification has raised a number of questions regarding how states are covering Plan B® for Medicaid-eligible women”. Some states could introduce Medicaid policies that “complicate access to Plan B® or exclude coverage altogether for low-income women” (NHeLP).
According to NHeLP’s report “Over the Counter or Out of Reach?: A Report on Evolving State Medicaid Policies for Covering Emergency Contraception”, South Carolina does not have a clear state policy after August 2006 that Medicaid will cover EC/Plan B® as an over the counter drug. EC is also not included on a Medicaid drug list, formulary, or PDL updated after August 2006. Likewise, a prescription is required for EC reimbursement under a 2005 or post-August 2006 pharmacy policy.
The good news is that prior authorization is not required for reimbursement of EC. Furthermore, reimbursement is possible in general for OTC drugs not specifically listed in agency regulations or documents through prior authorization. This means that EC could be included on the list.
So, what can you do to ensure that low income women in SC are still able to get their EC covered by Medicaid? The document “Emergency Contraception & Medicaid: A State-by-State Analysis and Advocate’s Toolkit” provides a lot of useful information and an action kit for advocates.
Follow the below action plan and checklist and contact the South Carolina Emergency Contraceptive Initiative to volunteer to become more involved.
An Action Plan for Advocates (read the details in the report)Action 1: Determine the Status of Medicaid Coverage of EC in Your StateAction 2: If Plan B® is Covered, Determine the Access BarriersAction 3: Document and Report Barrier IssuesAction 4: Educate Medicaid PersonnelAction 5: Educate Medicaid Recipients
Checklist: Do Medicaid Barriers to EC Access Exist in My State?□ How easy is it to find out whether Medicaid covers Plan B® in your state?□ Do you have a Medicaid drug formulary in your state?□ Is Plan B® listed on the formulary?□ If Plan B® is not listed on the formulary, what is the process for getting it on the formulary?□ Is Preven listed?□ How easy is it to obtain Plan B® if you are on Medicaid?□ Are individuals being charged co-pays?□ Does a Medicaid recipient need to obtain prior authorization for coverage of Plan B®?□ If so, are recipients receiving an emergency supply and a response within 24 hours?□ Do Medicaid personnel and websites provide accurate information about EC and coverage?□ Are there other utilization controls in place, such as a limit on the number of refills?□ Are individuals being forced to pay for EC out-of-pocket?□ Are there other barriers facing Medicaid recipients accessing EC?□ Are clinics and providers being reimbursed in a timely manner?□ Does your state enroll Medicaid beneficiaries into managed care plans on a mandatory basis?□ Is EC excluded from the managed care plan’s scope of covered benefits?□ If you are in a ‘pharmacy access’ state, you might want to ask these additional questions.□ What is the process for Medicaid reimbursement when obtaining EC from a pharmacy?□ Do pharmacists get reimbursed for time spent counseling patients?