Chris Koyanagi, policy director of the Bazelon Center for Mental Health
Law, told attendees at APA's 2004 annual meeting in New York City last month
that states have enacted a complicated array of policies to restrict access to
prescription drugs for Medicaid beneficiaries.
Mental health advocates, however, can find some glimmer of hope in the
results of a Bazelon Center survey of those policies conducted last summer and
updated early this year.
Koyanagi pointed out that prescription drugs make a likely target for
restrictions because their costs are increasing twice as fast as total
Medicaid costs. In 1998 antipsychotics and antidepressants accounted for 19
percent of total costs of prescription drugs in the Medicaid program.
According to a study by the Lewin Group, funded by the National Institute
of Mental Health and issued in January 2000, the use of atypical
antipsychotics in Medicaid has grown dramatically (Psychiatric News,
June 21, 2002).
Spending on those drugs jumped 160 percent between 1995 and 1998. The
introduction of atypical antipsychotics did not merely replace older
therapies, but instead expanded the market for use of those agents, according
to the report.
The Bazelon Center identified the prevalence in states of five restrictive
These policies are being applied in various combinations to antipsychotics
(typical and atypical), antidepressants (SSRIs and others), anticonvulsants,
antiparkinsonian medications, stimulants, and
The good news with regard to these developments, according to Koyanagi, is
the extent to which states are exempting drugs used to treat mentally ill
people from those policies.
Thirty-one of the 49 states requiring prior authorization have "some
exclusions" for such drugs. Of the 31, most do not require prior
authorization for antipsychotics and anticonvulsants. States more frequently
require prior authorization for antidepressants, stimulants, and
The use of a PDL is the most rapidly growing restrictive practice, said
Koyanagi. Of the 26 states with operational PDLs, 15 have some form of
exclusion for one or more of the drugs used to treat mental illness. Thirteen
states with PDLs do not subject antipsychotic medications to PDL
Of the 16 states that limit the number of prescriptions, five exempt one or
more drugs or group of drugs used to treat mental illness.
Fail-first policies frequently do apply to antipsychotic medications. Of
the 18 states with fail-first policies, nine require failure on a specified
antipsychotic medication before another medication can be prescribed. Seven
require failure on a generic drug before a specified brand-name drug can be
Koyanagi told the audience that states will continue to try to control
prescription-drug costs and that mental health advocates should work with
Medicaid officials to identify cuts that avoid a "meat-axe"
approach (see box on page
"Medicaid Policies on Outpatient Prescription Drugs: A Survey and
Discussion of Advocacy" was a presentation at the session "Wither
the States?," sponsored by the American Association of Community
Psychiatrists and the National Association of State Mental Health Program
Directors and supported financially by the Substance Abuse and Mental Health
The Bazelon survey results are expected to be posted online soon at<www.bazelon.org>.▪