Under federal law, Medicaid covers any FDA-approved drug as long as the drug company offers Medicaid a discount. This is often referred to as an open formulary. The state of Massachusetts has recently submitted an 1115 waiver proposing to allow its Medicaid program to use a closed formulary, which could cover as few as one drug for every therapeutic drug class.1
The American Cancer Society Cancer Action Network (ACS CAN) and many other patient advocates representing individuals with serious and chronic conditions are opposed to any Medicaid waivers that would impose this kind of limitation. These proposals could negatively impact millions of lowincome patients currently battling or who have battled serious, chronic, and life-threatening diseases by restricting access to new and innovative drug therapies offered in the Medicaid program.
The Effect of a Closed Formulary on Patients with Serious and Chronic Conditions
Prescription drugs have different indications, different mechanisms of action, and different side effects, depending on the person’s diagnosis and comorbidities. For example, there are well over one hundred recognized types of cancer, and no single oncology drug is medically appropriate for all cancers. Even within a given type of cancer, there are different treatments that are medically appropriate depending on the stage of diagnosis, previous treatment, and other factors.2
Providers take into consideration multiple clinical factors related to a patient’s condition when making treatment decisions. Making prescription medicines subject to a closed formulary would restrict a provider’s ability to make the best medical decision for the care of their patients, effectively taking the clinical care decisions away from the provider and patient and giving it to the state.
Patients suffering from chronic, life-threatening conditions need a guarantee of uninterrupted access to the prescription drugs critical to maintaining or treating their disease. Disruptions in treatment, including switching a patients’ medication mid-treatment, could negatively impact their treatment and health outcomes.
Medicaid is a crucial source of coverage for thousands of Massachusetts residents with serious and chronic health care needs. This proposal could severely restrict their access to critical therapies necessary to improve health outcomes. Therefore, we strongly urge the Centers for Medicare and Medicaid Services (CMS) to reject Massachusetts’ proposal to impose a closed formulary with only a single drug per therapeutic class.
1. The Commonwealth of Massachusetts Executive Office of Health and Human Services. (2017, Sept. 8). Re: Request to Amend
Massachusetts’ Section 1115 Demonstration MassHealth (11-W-00030/1). [Letter to Seema Verma, Administrator, U.S. Centers for
Medicare and Medicaid Services. Boston, Massachusetts.
2. National Comprehensive Cancer Network. NCCN Guidelines. 2017. Available at
https://www.nccn.org/professionals/physician_gls/f_guidelines.asp.