DEVAL L. PATRICK Governor
TIMOTHY P. MURRAY Lieutenant Governor

The Commonwealth of Massachusetts
Executive Office of Health and Human Services
Office of Medicaid
100 Hancock Street, 6th Floor
Quincy, MA 02171

JUDYANN BIGBY, M.D. Secretary
TERENCE G. DOUGHERTY Medicaid Director

April 2011
Dear Colleague,
The Massachusetts Department of Mental Health and the MassHealth Pharmacy Program are pleased to provide you with an update to our letter of January 2010 regarding behavioral health medications. This letter also reviews the current cost of behavioral health medications, and provides clinical information and recommendations for the prescribing of atypical antipsychotics.
Based on your feedback to our November 2009 educational letter regarding low dose quetiapine (Seroquel), and our review of sleep disorders and their treatment, the MassHealth Pharmacy Program relaxed quantity limits on hypnotic medications. This was done to encourage the prescribing of hypnotic medications that are preferred through evidence based guidelines rather than low dose quetiapine to treat insomnia. Since this initiative began, low dose quetiapine prescribing has decreased 3.2%. Please visit the MassHealth Drug List website at www.ma.gov/masshealth/pharmacy for updated prescribing trends on the antipsychotic medications.
In our prior communications, we also recommended and implemented utilization controls to encourage the utilization of generic therapies whenever appropriate. We continue to make these recommendations, which are based on safety, effectiveness, and cost. The MassHealth Pharmacy Program applies the same general concepts to all classes of drugs.   Behavioral health medication expenditures continue to account for approximately $181 million, or 35.5% of the total MassHealth Pharmacy budget, and we are committed to advancing high quality, cost-effective care for MassHealth members.
Second generation antipsychotic drugs account for nearly half of the MassHealth behavioral health medication expenditures ($94 million), or nearly 18.6% of the MassHealth Pharmacy budget. In furthering our focus on behavioral health medications, we have reviewed all name brand second generation antipsychotics. As a result of this review, we strongly suggest that they be prescribed for their primary indications only. Generic medications should be prescribed as first line medications prior to the use of branded options. Branded options are reasonable to use only when there is substantial evidence of superiority over the generic choice.   In this regard, we ask that you review the enclosed educational letter, which addresses the pharmacotherapy of Treatment Resistant Depression (unipolar depression). We hope this best practice information is helpful to you. Please join us in helping to promote high quality care for our members while reducing unnecessary costs. We look forward to working with you for the benefit of our members.
Sincerely,

Mary Ellen Foti, MD
Deputy Commissioner
Clinical and Professional Services
Massachusetts Department of Mental Health

Paul L. Jeffrey, PharmD Deputy Director Office of Clinical Affairs Director of Pharmacy MassHealth