An Overview of State Medicaid Policies for Mental Health Drugs

Kyle E. Hultgren, PharmD Candidate

Purdue University School of Pharmacy

Objective To provide an accurate overview of

current state Medicaid policies regarding mental health drugs

Methods Identify states with preferred drug lists

(PDLs) Isolate and quantify the use of mental

health drug policies Form clusters of similar policies Associate each state Medicaid

prescription drug benefit structure with a given policy cluster

Identify and Quantify PDL Use

Percent of PDLs That Control a Given Drug Class

44

52 52

72

8084 84

88

0

10

20

30

40

50

60

70

80

90

100

Typicals MAOI TCA Atypicals Non-Stimulant SSRI Misc. Ads Amph. & M-phenidate

Drug Class

Perc

en

t (%

)

74% (37) have a PDL of some form

68% of these 37 states have mental health drug policies in place

Chart displays percentage of policies that address various drug classes

Drug and Policy Clusters Drug classes most

commonly addressed through policies Antipsychotics Antidepressants ADHD medications

Three major arenas of PDL structure and function Brand-Generic

Policies Prior Authorization

Policies Treatment Algorithm

Policies

Brand-Generic Policies All generic medications are preferred over

brand name (mandatory generic substitution and therapeutic substitution)

Brands without generic equivalents may still be preferred

Providers may be able to override preferred status

Brand manufacturers may pay supplemental rebates to become competitive in the class

States: Florida, Alaska, Illinois

Florida Preferred SSRIs

Citalopram Lexapro

Citalopram HBr Paxil CR

Fluoxetine Pexeva

Fluoxetine HCl Zoloft

Table shows mix of both brand name and generic medications

Prior Authorization Policies Requires that specific criteria are met before

a prescription is dispensed May involve “fail-first” edits or time intervals Method of attempting treatment uniformity for

patients with identical diagnoses Moves toward a shared state and provider

responsibility for prescribing behaviors States: Maine, Massachusetts, Missouri

Prior Authorization Policy Example

Condition Submitted ICD-9 Diagnoses

Inferred Diagnosis

History Date Range

Attention Deficit Disorder without

hyperactivity

314.00

------

730 days

Attention Deficit Disorder with hyperactivity

314.01

------

730 days

Narcolepsy (stimulants only)

347 Subject to clinical review

730 days

Table 3: Missouri Prior Authorization for ADHD stimulant medications38

Under 18 years of age Š appropriate diagnosis 18 Š 23 years of age

o Appropriate diagnosis o Goals of therapy Š Current academic/work enrollment

Over 23 years of age with childhood onset and history of treatment o Goals of therapy Š Current academic/work enrollment

Approval and therapy may be subject to supervision by mental health specialist

Treatment Algorithm Policies The most state-centric set of policies Designed to initiate, change, direct, and

terminate patient drug therapy based upon written criteria

Designed using most current evidence in tandem with provider consensus lends credibility to the algorithm

Series of prior authorizations used as guideposts to ensure appropriate use

State: Texas

Summary Few states purely use one method for

creating mental health drug policies