VA Formulary Coverage Much More Limited than Ohio Medicaid

Summary

Across 8 therapeutic areas, the Veteran's Administration (VA) National Formulary covers 49 percent fewer drugs than Ohio's largest Medicaid managed care plan and 68 percent fewer drugs than the Ohio Medicaid preferred drug list (PDL).

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Avalere compared the VA to Ohio Medicaid formulary coverage for 326 medications across 8 therapeutic areas. Our analysis finds that the VA does not cover 224 of 326 medications examined. Ohio’s fee-for-service Medicaid PDL does not cover 90 of the medicines and Ohio’s CareSource Managed Care formulary does not cover 177.

The VA national formulary covers only 23% of the 326 medicines included in the analysis, though an additional 8.6% are available to certain individuals, depending on the site of care. In contrast, the Ohio Medicaid PDL lists 71% of the medications across the 8 therapeutic areas, while the Ohio CareSource formulary lists 45%. Ohio CareSource is the largest Medicaid plan in the state, which covers 53% of Medicaid managed care beneficiaries in Ohio.

The Pharmaceutical Research and Manufacturers of America provided funding for this analysis. Avalere maintained full editorial control.

Methodology

Avalere analyzed the Ohio Medicaid Preferred Drug List, the VA National Formulary, and the CareSource Formulary (the Medicaid managed care organization with the largest enrollment in Ohio) using the following publicly available documents: Ohio Medicaid FFS Preferred Drug List (April 2017), VA National Formulary (January 2017), and CareSource Ohio Medicaid Managed Care Formulary (April 2017). Avalere compared coverage for brand and generic medications across eight therapeutic areas: Antidepressants, Antidiabetic Agents, CNS Stimulants, HIV-AIDS, HMG-CoA Reductase Inhibitors, Insulins, Mental Health, and Respiratory Pulmonary Asthma. Several medications are categorized in more than one class or therapeutic area; for this analysis, duplicate drug entries were removed. There are 326 unique medications included in the analysis.

Medications were classified as covered, dependent, or not listed.* Coverage for medications categorized as “dependent” is dependent on the formulation or, in the case of the VA National Formulary, when coverage decisions about which formulations of agents to cover are made at the local level.

* Note: Medicaid programs must cover all drugs manufactured by companies participating in the Medicaid Drug Rebate Program. Drugs that are categorized as “not listed” on the Ohio Medicaid PDL and the CareSource Formulary should still be available to beneficiaries, though access may be subject to appeals processes.