Medical Assistance Program- Section 0348- RITE CARE PROGRAM

Regulation Authority:

RIGL 40-8; Title XIX of the Social Security Act

Purpose and Reason:

Effective February 1, 2009, the pharmacy benefit for RIte Care members will cover Generic-Only Drugs. The Department of Human Services (DHS) will specify certain allowed brand therapeutic classes/single agent drugs that are to be exempted from the generic-only formulary. Criteria for the approval of exemptions to generic-only formulary are outlined in DHS policy. Both members and providers will be informed of these changes prior to the implementation of the policy. RIte Care members will continue to have access to a comprehensive pharmacy benefit with a managed formulary. This change does not affect: Children with Special Health Care Needs [children with Supplemental Security Income (SSI), Katie Beckett eligibility, adoption subsidy, and those in substitute/foster care], Rhody Health Partners members or individuals with traditional Medicaid (fee-for-service) coverage.

Brief statement of Reason for Finding Imminent Peril:

An immediate effective date is necessary in view of my finding that any substantial delay might imperil the public health, safety, and welfare. This finding is based upon the following: Pursuant to the Rhode Island General Assembly legislation for FY 2008 which amended Rhode Island General Law Chapter 40-21-1 in Article 10 Substitute A “Relating to Medical Assistance- Managed Care,” This legislation created a generic drugs only pharmacy benefit for the RIte Care Program, authorizing the Department “ to mandate the dispensing of generic-only drugs with the exception of limited brand drug coverage for certain therapeutic classes as approved by the Department of Human Services to individual eligible for medical assistance (Medicaid) under sections 40-8.4-4, 42-12.3-4 and 42-12.3-15”. In preparing to implement this policy initiative, this Department drafted and posted regulations for public review and comment. Two public hearings were conducted (in October and December of 2008), and based on the significant public comments, this Department made substantial changes to the proposed regulations. Because the Department has already begun the preparation for implementing this policy change effective February 1, 2009, the Department is unable to post the proposed regulations containing the revisions requested by the public, and provide thirty days notice as required by statute. The Department is requesting the emergency filing in order to proceed with the February 1, 2009 implementation of the policy. The Department has mailed letters to members and providers, and the health plans have mailed letters to providers and members. Various stakeholder groups have been notified. Physicians and patients have been asked to review the prescriptions and switch to generic, if needed by February 1, 2009. Significant systems work has been completed to have the program implemented by the February 1, 2009. This includes website updates, provider notification, pharmacy benefit policies and procedures updates, customer service staff education, payment and claims systems updates, and additional quality monitoring and oversight. Contract rates have been actuarial established and contract amendments executed. The capitation payments have been configured in the DHS payment system and updates to the contract monitoring for the pharmacy benefit has been established. Pursuant to subsection (b) of § 42-35-3, the emergency regulations shall take effect upon filing with the Rhode Island Secretary of State and shall remain in effect as provided in said subsection. While the emergency regulations are in effect, regulations will be promulgated pursuant to subsection (a) of § 42-35-3. These emergency rules and regulations are available for inspection on the Department of Human Services website at www.dhs.ri.gov, or in the Office of Policy Development, Department of Human Services, Forand Building, 600 New London Avenue, Cranston, Rhode Island 02920, and will be available on the Rhode Island Secretary of State’s website: www.rules.state.ri.us/rules/