Provider Notice Issued 04/18/11

To:​	Participating Advanced Practice Nurses, Encounter Rate Clinics, Federally Qualified Health Centers, Hospitals, Local Health Departments, Pharmacies, Physicians, Rural Health Clinics and School-based Clinics​
Date: ​	​ April 18, 2011
Re:	Preferred Drug List Changes for Atypical Antipsychotics, Anticonvulsants, Antidepressants—SSRIs, Antidepressants—Other, and Stimulants/ADHD Agents​

  

The department is committed to ensuring continuity of care for patients currently on these medications, and for ensuring that patients have timely access to clinically-appropriate medications. Following is information regarding policies on prior approval and grandfathering of patients on existing therapy.

Grandfathering Policy

Depending on the drug, the department will grandfather certain existing patients on drugs that are moving to non-preferred status. In all classes, all new starts, as well as patients switching from a non-preferred drug, will require a therapeutic trial on the preferred products before being approved for a non-preferred product, unless there is a clinical reason that the patient must have a non-preferred product without first trying the preferred products.

Atypical Antipsychotics: Patients currently on an Atypical Antipsychotic who have a history of diagnosis of schizophrenia, bipolar disorder, depression, or autism will be grandfathered long-term on non-preferred products, with the exception of patients who are on a sub-therapeutic dose of Seroquel or Seroquel XR.

Anticonvulsants: Patients currently on an anticonvulsant who have a history of diagnosis of seizure disorder will be grandfathered long-term on non-preferred products.

ADHD Agents: Patients under the age of 18 with a diagnosis of Attention Deficit Disorder or Attention Deficit Hyperactivity Disorder will be grandfathered on non-preferred products long-term.

Antidepressants: Patients with a diagnosis of depression will be grandfathered on Cymbalta long-term. There will be no grandfathering on other non-preferred agents. Lexapro patients will be expected to switch to citalopram and Effexor XR patients will be expected to switch to venlafaxine immediate release, unless there is a clinical reason that these patients must use the non-preferred products. In that case, the provider must request prior authorization.

Prior Authorization

The department's current processing timeframe for prior authorization requests is approximately two hours. Prior authorization may be requested through the normal process, either by fax at 217-524-7264 or 217-524-0404; or by calling the Drug Prior Approval Hotline at 1-800-252-8942.

The department is committed to ensuring that providers are readily able to obtain the status of a prior approval request as well as the disposition of the request. For the above classes, if the provider includes their fax number on the prior approval request, the department will notify the provider of the disposition of the request via fax-back reply. Additionally, a provider may call the Drug Prior Approval Hotline to obtain that information.

Age Restrictions

Effective April 18, 2011, the department will require prior authorization for ADHD agents for patients over the age of 18.

Cost Containment

The department is making significant changes to its Preferred Drug List (PDL) in order to promote the use of lower-cost generic drugs when clinically appropriate. Rising health care costs across the country, along with decreased revenues resulting from the recession, have forced states across the nation to make tough decisions in order to sustain their Medicaid programs and ensure continued access to care. Further, over the past ten years, brand name drug prices have skyrocketed, according to studies published by the AARP and the Government Accounting Office (GAO), even at times when the rate of inflation plummeted to an all time low. Avoiding the unnecessary expenditures that result from the use of expensive brand name drugs, in cases where inexpensive generic alternative drugs are clinically appropriate, is an integral part of the state's Medicaid reform efforts. Without these and many other reform initiatives the department is undertaking, the Medicaid program would be unsustainable. Atypical Antipsychotics is the department's highest cost drug class, costing nearly $180M annually. The four classes, anticonvulsants, antidepressants, ADHD agents, and atypical antipsychotics, represent 25% of the department's entire drug budget. To provide some sense of the magnitude of the potential cost avoidance by simply shifting utilization to clinically-appropriate generics, each 1% shift in market share in these four classes from brands to generics saves the department approximately $6M.

Questions regarding this notice may be directed to the Bureau of Pharmacy Services at 1-877-782-5565, option 7.

Theresa A. Eagleson, Administrator
Division of Medical Programs

PDL Changes

In all classes below, products whose preferred status changed are in bold and marked with an asterisk.

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