Urgent Action Items:
- Urge your state representative and state senator to support legislation repealing or limiting the 4-drug restriction on Medicaid recipients. House Bill 3671 (Flowers) would repeal the 4-drug restriction. House Bill 2469 (Chapa LaVia) and Senate Bill 2611 (Hastings) would carve out many psychotropic medications from the 4-drug restriction. House Bill 3688 (Harris) would carve out generic psychotropic medications from the the 4-drug rule.
- Urge DHFS Director Julie Hamos to support legislation repealing or limiting the 4-drug restriction.
- Urge your state representative and senator to support legislation streamlining the prior authorization process for medications and requires all third-party payers to use the same forms.. House Bill 3638 (Fine) and Senate Bill 2585 (Kotowski) will accomplish this important goal. priorauthorizationletterallgroups101813
Background: Psychotropic medications play an important role in the treatment of serious mental illnesses. Many persons cannot survive safely in the community without such medications. Unfortunately, these medications are expensive. This has led insurance companies and government agencies, including the Illinois Department of Healthcare and Family Services (DHFS), to restrict access to such medications. The Mental Health Summit opposes restrictions on access to medications unless those restrictions are based upon sound clinical judgments about safety and efficacy. Our position is based upon the following key principles:
- While many psychotropic medications have similar efficacy rates, different medications are successful with different persons who have the same diagnosis. Additionally, medications which may seem quite similar often have quite different side effects for different persons. Psychiatrists and other physicians must often try several medications before they find one that works well and minimizes side effects.
- Preferred Drug Lists (PDL) can be a useful tool for reducing the price of medications by encouraging pharmaceutical companies to negotiate rebates, particularly for large volume purchasers such as DHFS and the Department of Human Services, Division of Mental Health. Since those medications not on preferred drug lists are usually available only with “prior authorization”, pharmaceutical companies may compete to be listed on the PDL.
- Unfortunately, prior authorization often amounts to a complete denial for people on Medicaid. That is because prior authorization is extremely burdensome on physicians and the Medicaid reimbursement rate for physicians, including psychiatrists, is so low that those physicians treating Medicaid patients have neither the time nor the staff to obtain prior authorization.
- Persons with serious mental illnesses constitute a large and disproportionate percentage of those persons eligible for Medicaid. Thus, prior authorization requirements directly interfere with the quality of care for persons with mental illnesses.
- DHFS has long had a practice of placing all new medications on prior authorization even though they have been approved by the Food and Drug Administration. This restriction also prevents persons with mental illnesses on Medicaid from benefitting from improvements in medications.
- Because Illinois system of care for people with mental illnesses is disjointed, different providers often have different lists of preferred psychotropic medications. As patients move from one provider to another, they may be forced to change medications. Switching a patient who is doing well on one medication to another medication is clinically unsound.
- The creation of two Medicaid managed care entities for the suburban Chicago area–Aetna and Illinicare–has made things worse. There are now three Medicaid preferred drug lists (PDLs) and three prior authorization processes for Medicaid recipients. Those physicians who are willing to accept Medicaid recipients must learn how to deal with these three burdensome systems. Medicaid recipients are often required to switch medications when they move from a short distance into or out of the areas served by Illinicare and Aetna–such as moving from Chicago to a neighboring suburb like Evanston or Oak Lawn or vice versa.
- Unless and until there are significant improvements in the Medicaid rate structure for psychiatrists and other physicians and/or imrovements in the process for obtaining prior approval, Illinois should maintain open access to all FDA-approved psychotropic medications.
- All psychotropic medications should be accessible to persons on Medicaid once they have been approved by the Food and Drug Administration. Illinois should copy states like Ohio which have exempted psychotropic medications from onerous restrictions.
- The Summit supports transparency concerning research on the safety and effectiveness of pyschotropic medications. Click here for the United State government registry for all clinical trials.
- Illinois should publish an easy-to-use guide for doctors to navigate the many different Preferred Drug Lists and prior authorization rules which exist for Medicaid patients now that managed care entities have taken over Medicaid administration for suburban Chicagoland.
- Medicaid should publish specific approval standards for prior authorization of psychotropic medications not on the Preferred Drug List and require the two Medicaid managed care entities in Illinois (Aetna and IlliniCare) to do this also.
- The Drugs and Therapeutics Committee should be subject to the Open Meetings Act.
- There should be at least one consumer member of the Drugs and Therapeutic Committee.
- Whenever there are changes to the Preferred Drug List or other policies relating to psychotropic medications for Medicaid recipients, Illinois should notify all affected Medicaid recipients in advance.
- DHFS should work with professional organizations to provide training to physicians concerning the three Medicaid Preferred Drug Lists and the three prior authorization systems currently in place for Medicaid patients.