Medicaid prescription drug policies: antipsychotic medications  

"A medication that works well for one person with schizophrenia often doesn’t work well for another. Genetic variations are thought to play a key role in this difference in response. While patients search for the right medications, their illnesses may worsen."

-The National Institute of Mental Health, Jan. 2008 

Psychiatric medications and vulnerable populations

Psychiatric medications play an important role in recovery for many youth and adults who live with mental health disorders. Psychiatric medications include several medication classes, including antipsychotics, antidepressants, antianxiety medications, mood stabilizers and anticonvulsants and stimulant and nonstimulant medications to treat ADHD. 

Finding the most helpful and well-tolerated medications and doses can take multiple trials because effectiveness and side effects vary significantly for every individual. Medication tolerance and continuation are often key to successful management of mental illness.

Why is open access important? 

Treatment adherence 

Nonadherence to treatment is a significant problem for people who live with serious mental illness.

The CATIE study reported that nearly three-quarters of individuals in the trials  stopped  taking their antipsychotic medications.

There are multiple reasons for treatment nonadherence of psychiatric medications, including intolerable side effects, lack of effectiveness, alleviation of symptoms resulting in an individual feeling that she or he does not need medications any more, lack of insight into one's illness-a clinical phenomena known as anosognosia-and personal perceptions. Due to the very nature of mental illness, an individual's willingness to take one medication or another may not be predictable. For this reason, open access is important in optimizing treatment adherence.

Positive outcomes 

While many psychiatric medications may exhibit similar overall rates of effectiveness, individuals have unique reactions to psychiatric medications.

According to NIMH, a medication that works well for one individual with schizophrenia often doesn't  work well for another. 

Because individuals who live with serious mental illness vary in their symptoms, medical histories, co-occurring health and substance use conditions and responsiveness, access to a full array of medication choices is vital for successful treatment.

What’s wrong with preferred drug lists and prior authorization? 

Unintended consequences of barriers to access 

Preferred drug lists and prior authorization requirements impose barriers for vulnerable Medicaid enrollees, many of whom have experienced failed treatment for mental illness. In addition, many individuals experience significant functional impairment as a result of the mental illness or co-occurring disorder that may impair insight into treatment needs and result in challenges in navigating system barriers.

Erecting barriers to accessing the right medication has the potential for devastating consequences for persons living with serious mental illness.

A 10-state study of Medicaid prescription drug policies revealed that use of preferred drug lists was associated with 5.4 times higher odds of medication access problems, including inability to get refills or new prescriptions, discontinuing or temporarily stopping a medication and being prescribed a medication that was not clinically preferred. Use of prior authorization was associated with 7.8 times higher odds of a medication access problem.

With the high stakes involved for persons living with mental illness, preferred drug lists, prior authorization and other utilization management techniques pose substantial risks for the very populations Medicaid is intended to serve.

What patient protections are needed when access is restricted? 

Shared clinical decision making 

To maximize good outcomes, the NASMHPD Medical Directors Council recommends promoting shared decision making. Decisions about past clinical response or clinical necessity for a nonpreferred medication should take into account past treatment history, other medical conditions, potential drug interactions,  side effects, tolerability and patient preferences, among other important clinical factors and should be made by the individual living with mental illness and his or her doctor.

Independent assessment of outcomes

Research suggests that preferred drug lists and restrictive prior authorization and utilization management practices result in negative outcomes for individuals who live with mental illness. Any restrictions in coverage of antipsychotics in preferred drug lists must include relevant data collection and independent assessment evaluating the effect on individual outcomes.

Continuity of care

Individuals who have responded to a medication in the past or are currently responding to a medication  must be able to continue to receive that medication  with no barriers such as increased  cost-sharing  or prior authorization.  "Grandfathering" provisions are essential to reduce relapse and support critical continuity of care.

Responsive, user-friendly and flexible processes

Prior authorization procedures or processes can present significant, even overwhelming, challenges for individuals who are living with mental illness and co-occurring disorders. The NASMHPD Medical Directors Council emphasizes that any prior authorization processes must be simple, responsive, user-friendly, timely and flexible. Performance  measures  must be developed  for ensuring rapid responses,  ease of prescriber use, temporary medication  supplies, simple exemption  and appeals processes  and other criteria that impact how individuals  living with mental illness and health care professionals experience  prescription  drug utilization management  policies.