Expansion of Formulary Brings Mixed Blessings

Among the latest changes in Tennessee's Medicaid program, known as TennCare, is the addition of hundreds of medications, including some antipsychotics and anticonvulsants, to the list of medications available to patients in the program. But the additions come with a major caveat.

The change is part of an ongoing and extensive overhaul of the program and will expand the list of medications TennCare enrollees can access from about 400 to more than 1,000. The change, which became effective February 1, will limit the new drugs to enrollees whose physicians say that the medications are medically necessary to avoid hospitalization, institutionalization, or death within 90 days. Beneficiaries who need one of the medications for chronic conditions could receive it for a year without having to go through the process again, said state health officials.

Prescription Limit Imposed

TennCare enrollees will continue to have their overall medication access limited to five prescription drugs—two brand name and three generic—per month.

Although the access to additional medications will help some patients, Lane Cook, M.D., president of the Smoky Mountain Chapter of the Tennessee Psychiatric Association, said that the continued five-drug limitation will hurt his patients who have multiple mental health problems and other comborbid conditions.

“There are some benefits with this change, but it could end up being cosmetic, because all of the atypical antipsychotics are brand-name drugs, and you can only use two of those,” Cook said.

The five-drug limit was imposed as part of a controversial 2005 overhaul of TennCare that cut 170,000 people from the public health program to reduce its drain on the state budget.

State officials maintain that most of TennCare's 1.2 million remaining enrollees have no trouble getting the drugs they need. The program has no prescription coverage limits for the 640,000 children enrolled, and about 43,500 adult TennCare enrollees have qualified for an exemption program that pays for more than five medications per month. TennCare offcials do not know how many other beneficiaries who do not qualify for the exemption seek more than five prescriptions a month. Those beneficiaries are required to pay the full cost of additional prescriptions.

Lane said the limit forces physicians to prioritize patients' medications, and sometimes patients don't receive the drugs they need because of the limits.

The state Medicaid program also is one of the few that does not cover benzodiazepines. Physicians were given a month to taper patients off benzodiazepine medications when TennCare's coverage was cut in 2005. Now the low-income patients must pay out-of-pocket monthly copayments for these drugs if their physician prescribes them.

“There are some people for whom another $15 a month is beyond their means,” Cook said.

State Medicaid officials have selected the 600 new drugs eligible for coverage, but the list was not available by press time. The list encompasses 15 categories of drugs, including antibiotics, antipsychotics, and anticonvulsants.

Filling the Medicaid Gap

The state also launched an initiative called CoverTN to help restore coverage to some residents who lost their Medicaid eligibility in the 2005 reduction, including coverage for mental health and substance abuse treatment.

Tennessee awarded BlueCross BlueShield of Tennessee a contract in December 2006 to provide health coverage for low-income, uninsured workers through the CoverTN program. CoverTN is part of the governor's Cover Tennessee program, which aims to expand health coverage for low-income, uninsured working adults who do not qualify for Medicaid.

Blue Cross/Blue Shield will provide coverage for an average monthly premium of $150 per beneficiary. The state will pay one-third of the premiums, while employers will pay another third, and employees will pay the remaining third. The insurer will offer plans in two tiers, and the plans will cover basic health care services with no deductibles and an annual coverage limit of $25,000. Services covered will include inpatient and outpatient procedures, physician services, diagnostic tests, and mental health and substance abuse treatment.

About 45,000 people are expected to enroll in the plan within the first full year at a cost to the state of $35 million. If more residents enroll, the governor has said that he will request additional funding from the state legislature. CoverTN will begin in March 2007.

More information on TennCare is posted at<www.state.tn.us/tenncare/>.▪