Medicaid Formulary Restrictions May Increase Costs
A prior authorization involves a phone call or a fax, and is nearly always approved when requested, which is less stringent than many states. However, web-based authorizations are not available. The phone call must be made by the prescriber and takes about 5-8 minutes. This is sometimes onerous for busy clinicians, who may instead choose to complete the fax form. The faxed authorization takes up to 24 hours to complete so the patient who goes to the pharmacy on the same day may be told that the medication has not been authorized.
The look-back period is key in determining who is considered to be “drug-naïve.” The P&T committee members originally developed the concept of “drug-naïve” to limit the need to obtain prior authorizations only for those patients who had never been on antipsychotics. The idea was that those who have a history of taking antipsychotics -- including those who did particularly well or poorly on a Tier 1 drug or those who were unable to tolerate these drugs due to side effects -- would not have to go back and take a Tier 1 medication again and could get a “free pass” to get Tier 2 medications without jumping through the hoop of obtaining a prior authorization. This concept was undermined by adding a rule that patients who are “drug-naïve” are defined as such by whether they had outpatient prescriptions filled during the “look-back period.”
The look-back period for determining whether someone is “drug-naïve” is now 120 days. Here is the effect of this scheme: If a patient does not get two prescriptions filled (actually, a total of 42 days worth of medications) during the most recent 120 days, then the patient’s status reverts back to “drug-naïve” and the patient has to start all over. So, if a patient is non-compliant for 4 months, or receives samples for 4 months, or is hospitalized or imprisoned for 4 months, and so does not get at least 2 prescriptions filled during that time period, then the patient now becomes “drug-naïve” -- even if the patient has failed medication trials or has had unacceptable side effects in the past. The patient has to either go through the Tier 1 drugs again OR go through the prior authorization process again.
This does not make clinical sense. The Kaiser pharmacist on the committee indicated that they look back as far as they have data to make such decisions. So the committee unanimously voted to extend the look-back period to 2 years in August 2010, but the DUR committee rejected this as unnecessary and costly.
It is hoped that an independent group will soon be able to review the pharmacy and inpatient and outpatient databases to analyze the downstream effects of these medication access decisions. In an era of cost containment and evidence-based medicine, we all want to be sure that states are not being penny-wise and pound-foolish.
—Steven Roy Daviss, M.D., DFAPA
Dr. Daviss is co-author of Shrink Rap: Three Psychiatrists Explain Their Work, chair of the department of psychiatry at the University of Maryland’s Baltimore Washington Medical Center, and serves on the Maryland Medicaid Pharmacy Program’s Pharmacy and Therapeutics Committee. He can be reached on Google Plus, Twitter, and Facebook.
