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DVHA asks committee to exclude Medicaid from H.611 HIV medication cost-sharing amendment, warns of fiscal and program risks
Summary
Alex McCracken of DVHA told the Senate Health & Welfare Committee that Vermont Medicaid already covers PrEP/PEP and many HIV treatments without prior authorization or copays and asked that the H.611 amendment requiring no cost-sharing exclude Medicaid because of significant fiscal impact and federal program requirements.
Alex McCracken, director of communications and legislative affairs for the Department of Vermont Health Access (DVHA), testified on April 17 that the department requests Medicaid be excluded from a proposed amendment to H.611 that would require insurers to provide HIV prevention and treatment medications with no cost sharing.
"This language would require insurers, including Medicaid, to provide additional coverage for HIV prevention and treatment medication with no cost sharing," McCracken said. He told the committee that Vermont Medicaid already covers brand and generic formulations of PrEP and PEP without prior authorization, including long-acting injectables, and that many HIV treatment drugs are available without PA or step therapy. He also said PrEP drugs do not carry a copay for Vermont Medicaid members.
McCracken said a primary fiscal concern is the impact on DVHA's ability to manage the drug class to secure the lowest net cost to Medicaid. "The impact is due in part to the increased utilization, but largely due to the loss of DVHA's ability to manage the class for the lowest net cost to Medicaid, which allows us to capitalize on rebates," he said, adding that DVHA is working to estimate the total cost.
He also raised program-integrity and operational concerns: federal scrutiny of Medicaid program integrity nationwide and the high reimbursement amounts for some HIV medications make them a potential target for fraud, and the amendment's provider-authority language is not workable as written because CMS requires providers to be enrolled in Medicaid.
McCracken asked the committee to exclude Medicaid from the amendment, offer to provide a written fiscal estimate, and suggested continuing discussion in the 2027 session if needed. The committee asked for written testimony and suggested that DVHA provide alternative language or cross-outs the committee could consider.
