Medicaid MCOs: Market Landscape Trends, Contracting Environment and Manufacturer Engagement

The managed Medicaid segment continues to be impacted by government mandates and CMS policy changes, as well as fluctuations in enrollment in 2024. HIRC's report, Medicaid MCOs: Market Landscape Trends, Contracting Environment and Manufacturer Engagement, reviews the Medicaid MCO market landscape, the contracting environment, and pharmaceutical manufacturer engagement. The report addresses the following questions:

• What is the nature of the current Medicaid MCO market? Which plans account for the majority of market share?
• What top market trends are impacting the Medicaid MCO segment? Which strategic imperatives are Medicaid MCO leaders working to address over the next 12-18 months?
• What activities are Medicaid MCOs engaging in to better manage drug costs and utilization?
• What is the current contracting environment across 20+ therapeutic areas? Which contract types are most frequently offered and what are the most common rebate/discount amounts?
• Which manufacturers are most often nominated as Medicaid MCOs' overall "Partner of Choice"? How do manufacturers benchmark across willingness to offer supplemental discounts/rebates, and overall quality of programs/resources?

Key Finding: Top market trends reported by Medicaid MCOs for 2024/2025 include the Inflation Reduction Act (IRA)/Federal & State Regulations, Increased Use of GLP-1s, Gene Therapy & Orphan Drugs, and Pharmacy Carve-out/Single PDL.

Medicaid MCOs' Utilization Management Strategies in 2024. To better manage drug costs and utilization of medications over the next 12-18 months, Medicaid MCO panelists report focusing on More Rigorous Prior Authorization Criteria, followed by Increased Use of Step Edits. Secondary initiatives to manage drug costs include Enhancing Data Sharing Capabilities to Ensure Accurate Prescribing, Incentivizing Physicians to Use Generics/Lower Cost Drugs, and Driving Better Contract Offerings with Manufacturers.

MCOs Report Highest Contracting Activity in Airway Diseases and Diabetes. Medicaid MCO key decision-makers were asked to consider a list of 20+ therapeutic areas/disease states and indicate if their organization currently has a contract in-place or has been offered a contract in the past 12-18 months, beyond the mandatory required rebate. About 48% of Medicaid MCOs have or have been offered a supplemental contract for airway diseases and/or diabetes - SGLT2 inhibitors. The full report examines the contracting environment (contract types & supplemental discount amounts) in detail.

Research Methodology and Report Availability. In October 2024, HIRC surveyed 27 Medicaid managed care organization (MCO) pharmacy and medical directors from national, regional, and BCBS plans. Online surveys and follow-up telephone interviews were used to gather information. The complete report, Medicaid MCOs: Market Landscape Trends, Contracting Environment and Manufacturer Engagement, is available now to HIRC’s Managed Markets subscribers at www.hirc.com.

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