Illinois doctors need Medicaid preapproval for 17 mental health drugs

They say the formulary change is a hassle but acknowledge that it's designed to help balance the state's budget.

By Doug Trapp — Posted Sept. 16, 2011

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Illinois budget woes have led the state's Medicaid agency to place an administrative hurdle in front of physicians seeking coverage for certain medications to treat depression, psychosis, attention-deficit/hyperactivity disorder and other illnesses. Patient advocates say the barrier is affecting care.

Beginning in May, the Illinois Dept. of Healthcare and Family Services excluded 17 drugs from its preferred drug list, meaning that physicians who wish to prescribe these medications must call or fax to obtain a coverage preauthorization. The list of drugs moved to the nonpreferred list includes relatively new treatments such as aripiprazole, also known by the brand name Abilify.

The Medicaid agency expects that the change will save the state $90 million in its first year. The agency spends nearly $180 million a year on atypical antipsychotics -- the department's most expensive drug class. The four classes -- anticonvulsants, antidepressants, ADHD agents and atypical antipsychotics -- represent 25% of the department's drug budget, according to the April 18 agency announcement of the formulary changes.

"It's not a terribly unreasonable thing to do. It's just time-consuming, and there's already a shortage of psychiatrists," said Daniel Yohanna, MD, past president of the Illinois Psychiatric Society and vice chair of the Dept. of Psychiatry and Behavioral Neuroscience at the University of Chicago Medical Center. Dr. Yohanna said he typically spends 20 minutes completing a preauthorization required for nonpreferred drugs. So far he's completed about one a week, most of which have been approved.

Mike Claffey, a spokesman for the state Medicaid agency, said physicians often justify prescribing nonpreferred drugs by demonstrating that the preferred versions did not work. The less expensive versions of the drugs usually are just as effective as the brand-name versions, Dr. Yohanna said. However, some of the preferred drugs have undesirable side effects for patients, such as weight gain, diabetes and tremors.

The agency consulted an advisory committee composed of physicians before instituting the drug list changes. The Illinois State Medical Society Committee on Drug and Therapeutics recommended drugs for the nonpreferred list based on evidence and efficacy compared with similar generic drugs. The committee -- as well as the Illinois State Medical Society -- prefers to have an open formulary, but the members recognized that state budgets have limits.

"We feel an obligation that all drugs should be available to our patients," said Shastri Swaminathan, MD, a psychiatrist in Chicago and a committee member. "Having said that, we also need to be fiscally sensitive. If there is no money to pay and if we bankrupt the system with these expensive drugs, then the patients won't have any drugs to take." Some of the brand-name drugs moved to the nonpreferred list cost up to 40 times as much as generic versions, he said. Dr. Yohanna also is a committee member.

The committee pushed for some compromises, and the state agreed to keep two of the drugs in the open formulary. The state also grandfathered coverage for expensive drugs that patients had taken in the six months before the change took effect in May, Dr. Swaminathan said.

But some advocates for mental health patients are not satisfied. The preapproval process has unnecessarily restricted access to the most effective medications for certain patients, according to an Aug. 11 letter sent to the Medicaid agency by Mental Health Summit, a coalition of about 50 mental health care, patient advocacy and other organizations.

Some patients who moved from one system of care to another have reported having difficulty obtaining their prescribed drugs, which led some to stop taking their medications. Coalition members want the state to return to an open Medicaid drug formulary for antipsychotic drugs and to accept nonpreferred drug requests online, among other changes.

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