With approximately 25 percent of the state’s already-constrained budget consisting of Medicaid spending, Illinois has been desperately searching for places to make cuts in the program. One of those places is prescription drugs prescribed for mental health, including antidepressants, antipsychotics and attention-deficit disorder drugs. Nationwide, nearly a fifth of Medicaid prescription drug spending goes to behavioral health drugs, making the program the largest payer in the country for mental health treatment. In addition to capping Medicaid beneficiaries’ prescriptions to four per month, the state has chosen 17 brand name psychiatric medications that must receive prior authorization from the state’s Medicaid program. To receive authorization, the prescribing physician must explain why cheaper alternative drugs are not sufficient to meet the beneficiary’s medical needs.
There is no question that the prior authorization requirement has cut program spending on psychiatric drugs, considering that Illinois’ budget for such drugs was reduced by $112 million last year after implementation of the requirement. State Medicaid officials consulted with experts before imposing the requirement and found that often, generic drugs with the same or similar active ingredients were acceptable substitutes for expensive brand name drugs. For instance, both the popular antidepressant Lexapro and its generic version contain identical active ingredients. The main difference: A month’s supply of Lexapro costs $110 and the generic, citalopram, costs $7.
However, psychiatric providers are quick to point out that despite having the same active ingredient, the differing inactive chemicals can make a difference. The inactive ingredients can be responsible for the onset of undesirable side effects, some that can interfere with treatment of the base condition. One pharmacy technician cited additional symptoms of depression, weight gain, and sexual dysfunction as side effects she had seen in patients who switched to the generic antidepressant. She expressed concern about switching patients to other drugs in order to build a case for the Medicaid program that the patient actually should be on the brand name drug; she stated that one such patient was even hospitalized as a result.
Her concerns are shared by other mental health advocates such as the Community Behavioral Healthcare Association, which issued a letter to the state citing other problematic cases. One issue it raised is the relationship between the approved generic antipsychotics and serious metabolic conditions including diabetes and high cholesterol.
Studies by the publications Psychiatric Services and Health Affairs support these concerns. Information obtained by psychiatric doctors showed that many patients unable to obtain the appropriate drugs suffered adverse events including suicide, hospitalization and homelessness. One study revealed that nearly half of Medicaid patients being treated for mental disorders had trouble obtaining medication; nearly 25 percent of those patients ended up ceasing medication as a result.
Illinois officials defend their decision to implement the prior authorization requirement for these drugs. Evidence supports their conclusions that many of these drugs are over-prescribed, and that the need to obtain authorization will force doctors to give serious thought as to their reason for prescribing the expensive brand names over the generic versions. The authorization requirement does not prevent physicians from prescribing the brand name drugs to their patients; it just requires them to provide a legitimate explanation. Although critics see the process merely as more bureaucratic red tape.