Part D limits access to psychotropics

March 6, 2006

Coverage for psychotropic drugs under Medicare Part D is under fire. The goal of covering all or substantially all products and providing appropriate care for all patients is not being met.

Coverage for psychotropic drugs under Medicare Part D is under fire. The goal of covering all or substantially all products and providing appropriate care for all patients is not being met.

Most mental health patients were covered by Medicaid until Part D took over prescription drug benefits on Jan. 1, Alter noted. Most of those patients have been affected by the change. Widely used products such as Lexapro (escitalopram, Forest) are not included in many Part D formularies. Barbiturates and benzodiazepines are excluded from coverage. Most plans do not cover agents used to treat drug dependence and substance abuse.

Few of these problems are insurmountable, at least on paper. Prescribers can request prior authorization or an exception for agents they consider more appropriate than formulary choices. Plans must respond to expedited requests within 24 hours. If the request is denied and the prescriber persists, the case must be heard by an administrative law judge within seven calendar days.

But there's no guarantee the request will be approved. And simply having to request an exception or a prior authorization discourages many prescribers. "As easy as prior authorization sounds, it is just another obstacle to appropriate therapy," said John Avolio, pharmacy director at Diamond Drugs, the largest long-term care pharmacy provider in Pennsylvania. "Plans know that many doctors won't do the extra work."

The problems should not have been a surprise. A National Health Policy Forum (NHPF) in July 2004 warned that mental health patients would be especially vulnerable to formulary decisions that force changes in drug therapy.

The most vulnerable population is 7.2 million dual eligibles-patients covered by Medicaid who were also eligible for Medicare. Prescription drug coverage that had been provided by Medicaid is now covered by Part D. NHPF predicted that the change in coverage would require changes in long-established and well-tolerated drug regimens.

In 2005, the American Society of Consultant Pharmacists, the American Psychiatric Association, and the National Mental Health Association warned that Part D was on track to harm patients by limiting psychotropic product selection.

Practicing pharmacists added their own warnings later in the year. "Long-term care patients are going to be getting drugs that are less than optimal under Part D," Avolio told Drug Topics last November. "We are going to see more side effects because of restricted drug choices. We will be using fewer sustained-acting medications, which will increase staff workload and decrease compliance. Without significant changes, Part D is going to drive up overall costs with more side effects, more monitoring, more lab tests, and more hospitalizations."

Drug selection shrinks

Antidepressants have emerged as a big problem area. In June 2005, the Centers for Medicare & Medicaid Services directed Part D plans to cover all or substantially all drugs in the category. But when it came to selective serotonin reuptake inhibitors (SSRIs), the agency allowed plans to cover either escitalopram or citalopram (Celexa, Forest).

"We were mystified as to why this one drug was singled out," said Tom Clark, ASCP director of professional affairs. "We haven't seen any signs of change in coverage plans."