Medicaid Managed Care Common Formulary

McLaren Health Care

The Michigan Department of Health and Human Services (MDHHS) has worked with its health plan partners to create a list of drugs that all Medicaid health plans must cover. This list is called the Michigan Medicaid Managed Care Common Formulary.

MDHHS will implement this formulary that is common across all Medicaid health plans effective June 1, 2016.  The timeline for implementation will require all health plan enrollees to transition to the common formulary by October 1, 2016.

Additional information as well as a copy of the drug formulary can be found at:
http://www.michigan.gov/documents/mdhhs/Managed_Care_Common_Formulary_Listing_506275_7.pdf

Health Plans will send at least one notice to the member and one notice to the member’s prescriber if the patient’s drug is not on the Common Formulary and the member’s options to continue drug treatment (prior authorization procedures and appeal process).

Drugs in the following “protected” classes will receive grandfather status:

  • Antineoplastics
  • Immunosuppressants
  • Disease-Modifying Medications for Multiple Sclerosis

Health plans must allow beneficiaries to remain on drugs in these protected classes for 12 months regardless of whether the drug is non-covered or covered with prior authorization on the MCO Common Formulary.  After 12 months the health plan may require prior authorization for the beneficiary to continue coverage of grandfathered drugs.

The Common Formulary only applies to claims paid by Medicaid managed care organizations.  It does not apply to Medicaid fee for service members.

If you have any questions, please feel free to contact Kathy Condon at Kathy.Condon@McLaren.org or (248) 484-4940.