By Walter Hill and Brian Hepburn, M.D.
[Winter 2003; Vol. 29, No. 2; Pg 11]
Mental health drugs constitute 35 percent of Medicaid's total pharmaceutical cost to Maryland, said Debbie Chang, Department of Health and Mental Hygiene Deputy Secretary. "Ninety to 100,000 people are affected by the mental health part of the program [Medicaid]," she said. "We're looking for $20 million in savings."
To hold down the cost of prescription medications for the state's Fee for Service (FFS) Medicaid population, Maryland's Department of Health and Mental Hygiene (DHMH) is developing a list of preferred medications from which physicians may choose without having to seek pre-authorization. The majority of non-psychiatric Medicaid medications are prescribed under the Managed Care Organizations and are already prescribed from a restricted formulary. The new plan for the FFS medications is to take effect in early 2003. All atypical antipsychotic medications will continue to be available on the formulary and will not be restricted.
DHMH efforts to pare the cost of Medicaid come as a result of bills introduced in both the Maryland House of Delegates and Senate last year. Each bill passed its respective body. However, the reconciliation committee was unable to iron out differences in the two bills before adjournment in April. Neither version calls for limitations on psychotropic medications available for physicians to prescribe.
The DHMH plan calls for inclusion of at least two drugs in each therapeutic class when there are at least four possible drugs from which to choose. A Pharmacy and Therapeutics Committee will be appointed by the Department of Health and Mental Hygiene Administration to determine which drugs will be on the list. The legislation in both houses calls for a consumer representative to sit on the committee. DHMH, which will appoint two consumer representatives, was unclear at the August 16 meeting as to what role the consumers would play on what is essentially a professional committee otherwise composed of five pharmacists and five clinicians. The Committee will meet regularly to review drugs on the list and may add additional drugs within a classification if deemed appropriate. Chang met with representatives of the Washington Psychiatric Society, Maryland Psychiatric Society, NAMI and the Pharmacists' Association on August 16, said DHMH will seek the input from the psychiatric associations to help in identifying potential committee members.
According to Chang, prior authorization must be sought from a review panel before a non-listed drug can be prescribed to Medicaid patients. She indicated that DHMH will respond to prior authorization requests within 24 hours. The Department will respond to requests for reconsideration of adverse decisions within two business days. When prior authorization is not granted within the 24-hour time frame, a 72-hour emergency supply of the prescribed drug will be dispensed.
The Washington Psychiatric Society (WPS) raised the issue of how best to serve Marylanders now taking psychotropic medications that will not be on the 2003 list. Chang took the concern seriously and said DHMH would grandfather in these patients so that they will not have to change medications. She said that the development of the preferred-drug list will be based on clinical efficacy. The guaranteed time frames for prior authorization responses and the appeals process will also protect patients. Chang said that the state will receive a rebate from pharmaceutical houses whose products are used as part of the list. WPS and MPS representatives agreed that this is an issue that the two professional societies should monitor carefully to avoid even a hint of impropriety.
Mr. Hill is the executive director of the WPS. A version of this article appeared in the WPS newsletter.
**Legislation to exclude all psychotropic medications from the Medicaid preferred drug list has been introduced in the Maryland General Assembly as HB363 and SB676.**