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Pharmacy Benefits Management Program
About the Vermont Health Access Pharmacy Benefit Management Program:
In February 2000, the Governors of Maine, New Hampshire, and Vermont met to discuss the health and insurance-related issues that were being experienced by their states. In the course of that discussion, it was clear that all three states were experiencing rapidly rising prescription drug use and expense in their publicly administered programs and that there was a common interest in better management of this benefit area. The result was the Tri-State Pharmacy Initiative.
Since that time all three states have utilized pharmacy benefit manager (PBM) services to provide necessary expertise in maintaining and enhancing quality of care; controlling pharmacy expenditures; and reducing state administrative costs through collective procurement for states.
The Vermont Health Access PBM Program includes Maximum Acquisition Cost (MAC) pricing; prior authorization (PA) requirements; application of the generic drug requirements authorized by the Vermont General Assembly's Budget Act of 2002; messaging at the pharmacy point of sale during drug claims processing; prospective and retrospective drug utilization review (DUR); and a preferred drug list (PDL).
The PDL is a key feature in the Vermont pharmacy best practices and cost control program authorized by the State Fiscal Year 2002 Budget Act and Act 127 in 2002. The PDL identifies drugs that are clinically effective, but less costly. If a drug is not listed as "preferred" in a particular category on the PDL, it requires Prior Authorization in order for the drug to be covered.
The first phases of the Vermont Health Access PBM Program were implemented in November 2001. Prior to the PBM program, Vermont only required prior authorization on a limited number of drugs for clinical reasons. Starting in March 2002, the first iteration of the PDL was completed, with PA required for any drug not identified as "Preferred" in identified PDL classes. Starting on September 30, 2002, additional classes were systematically rolled out though December 9, 2002.
In the spring of 2003 Vermont joined a multi-state Medicaid pooling initiative that made possible combining the purchasing power of Vermont with other states in negotiating supplemental rebates with pharmaceutical companies. Since then, changes have been applied to the PDL to reflect new and/or more economically priced clinical options.
Vermont became a member the Sovereign States Drug Consortium (SSDC) in the fall of 2005. The SSDC is a Medicaid pool currently consisting of Iowa, Maine, and Vermont. Through the SSDC, Vermont plans to continue to see opportunities to contain costs in its PBM program.
