Against a backdrop of genetic code, Thomas Insel, M.D., tells
psychiatrists at APA's 2005 annual meeting in Atlanta that in the
not-too-distant future, they will be able to treat patients based on their
unique genetic variations. Insel is the director of the National Institute of
Mental Health. See page
12. David Hathcox
Prescription drug plans participating in the new Medicare Part D
prescription drug benefit must include "all or substantially all"
antidepressant and antipsychotic medications on their preferred drug
That directive came last month from the Centers for Medicare and Medicaid
Services (CMS) in the "Frequently Asked Questions (FAQs)" section
of its Web site in answer to the question "Why is CMS requiring `all or
substantially all' of the drugs in the antidepressant, antipsychotic,
anticonvulsant, anticancer, immunosuppressant and HIV/AIDS
The FAQ was posted in response to significant concerns and questions raised
since January, when the agency issued its final guidance to prescription drug
plans (PDPs) on the development of Part D formularies (Psychiatric
News, March 4). While trying to answer some questions, however, CMS seems
to have raised some new ones.
In the final guidance, CMS noted that its "expectations are that
best-practice formularies contain a majority of drugs within the following
classes: antidepressants, antipsychotics, anticonvulsants, antiretrovirals,
immunosuppressants, and antineoplastics. Following common best practices, CMS
will check to see that beneficiaries who are being treated with these classes
of medications have uninterrupted access to all drugs in that class via
formulary inclusion, utilization management tools, or exceptions processes.
When medically necessary, beneficiaries should be permitted to continue
utilizing a drug that is providing clinically beneficial outcomes."
While the FAQ suggests that patients will have access to a variety of
psychiatric drugs, it has no bearing on the exclusion of benzodiazepines from
Part D coverage. That exclusion is mandated by the law that created Part D,
the Medicare Modernization Act of 2003. As this issue went to press, Rep.
Benjamin Cardin (D-Md.) introduced HR 3151 to reverse the exclusion of
benzodiazepines. More information on the bill will appear in the next
After the FAQ was posted, questions quickly arose regarding its language.
For example, what does "contain a majority of drugs" really mean?
CMS acknowledged that in training sessions and phone calls, PDPs had asked for
an explanation of how a formulary could meet the "inclusion"
standard expected by CMS while continuing to make use of "utilization
management tools or exceptions processes." In short, critics said, the
policy appears to be contradictory.
CMS said in the FAQ that it has "consistently explained that [the
policy] meant that access to all or substantially all drugs in these specific
categories needed to be addressed by plan formularies."
The FAQ goes on to say that "`substantially all" in this
context means that all drugs in these categories are expected to be included
in plan formularies, with the "specific exceptions noted" at the
end of the FAQ in the section headed "Note (Attachment I)." One of
the five exceptions listed is of particular interest to the mental health
community. The note states that "all formularies must include either
escitalopram [Lexapro] or citalopram [Celexa]."
CMS states that the list of exceptions should not be viewed as a list of
exclusions and that each PDP's Pharmacy and Therapeutics Committee will have
the final say on whether the plan covers only escitalopram or citalopram, or
In the FAQ document posted on June 15, CMS did not explain why formularies
are directed to include escitalopram or citalopram, but not both. However, a
version of the FAQ posted on June 10 stated, "Either escitalopram or
citalopram may be left off formularies since escitalopram is the component of
citalopram that is responsible for the antidepressant effect."
Pharmacologically, the agency is correct about escitalopram's
antidepressant effect. Escitalopram, which was developed by Forest
Laboratories as a successor to citalopram, contains half of the active
ingredient found in the older product. The active ingredient occurs as nearly
identical chemical isomers, which exist as mirror images of one another.
Escitalopram—designated chemically as"
S-citalopram"—is the half thought to be responsible for the
medication's antidepressant effect. However, citalopram is roughly half
S-citalopram and half R-citalopram. The R-isomer, which does not have
antidepressant effects, is thought to interfere somewhat with the S-isomer's
beneficial effects. In addition, the R-isomer is thought to be responsible for
many of the adverse effects of citalopram. By eliminating the R-isomer from
the parent compound, Forest aimed to produce a better tolerated and more
After reviewing the FAQ posted on June 10, mental health advocacy
organizations, including APA, the National Alliance for the Mentally Ill, the
National Mental Health Association, and the Treatment Effectiveness Now
Project, brought their concerns to CMS. They fear that PDPs will choose to
cover the less-expensive generic citalopram over escitalopram, which is
available only as the Lexapro brand, despite the fact that the two drugs are
not interchangeable, pharmacologically or therapeutically.
The final FAQ eliminated the suggestion that the two drugs are
therapeutically interchangeable and noted that all formularies had to include
Overall, the policy as stated in the FAQ appears to ensure broad access to
nearly all psychotropic medications through the PDPs approved by CMS to
participate in Medicare Part D, noted Irvin L. "Sam" Muszynski,
J.D., director of APA's Office of Healthcare Systems and Financing. The policy
also appears to protect patients who are now covered under Medicaid and will
transition to Part D on January 1, 2006, by ensuring that their existing
medications will continue to be covered—even escitalopram.
Muszynski added, however, that it remains to be seen whether patients who
are prescribed escitalopram for the first time after January 1, 2006, will be
able to get it through their PDP.
"The policy expressed in the CMS guidance and clarified in the FAQ
document clearly represents a major step forward in ensuring continuity of
care for dual-eligible patients transitioning to the new benefit,"
Muszynski said. "The policy generally reaffirms the position APA and our
partners... have been strongly advocating from the beginning: that [individual
medications within the antidepressant and antipsychotic classes] are not
therapeutically interchangeable. We remain concerned, however, about how to
interpret certain parts of the guidance [that] continue to appear
Muszynski and the staff in APA's Division of Advocacy are continuing to
monitor and analyze CMS's developing policies regarding the implementation of
The CMS FAQ document can be accessed online at<http://questions.cms.hhs.gov/cgi-bin/cmshhs.cfg/php/enduser/std-alp.php>
by searching on the word "antidepressants." ▪