The Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid
100 Hancock Street, 6th Floor
Quincy, MA  02171
DEVAL L. PATRICK	JUDYANN BIGBY, M.D.
Governor	Secretary

TIMOTHY P. MURRAY	JULIAN J. HARRIS, M.D. Lieutenant Governor		Medicaid Director

See also the Second-Generation (Atypical) Antipsychotic Letter, May 2012.

Dear Prescriber,

April 2012

The MassHealth Pharmacy Program and the Department of Mental Health want to continue working with you regarding the management of the second generation antipsychotics, also known as atypical antipsychotics. In doing so, our goal is to continue our efforts in advancing high quality, cost-effective care for MassHealth members. Our management approach to date has included, among other things, dose consolidation, prior authorization requirements for polypharmacy, prior authorization requirements for certain of the newer brand name agents, and educational mailings regarding best practices for the safe and appropriate use of Seroquel® and Abilify®. We have recommended and have implemented utilization controls or other measures to encourage the utilization of generic therapies when clinically appropriate. These recommendations and measures have been based on safety and effectiveness first, and second on cost, and are general concepts that the MassHealth Pharmacy Program applies to all classes of drugs.

We have noticed, however, that despite the introduction of generic risperidone, which has significantly decreased the cost of that agent, the MassHealth expenditure for second generation antipsychotic medications has been steadily rising. We project that MassHealth will pay $96 million this fiscal year for these medications, approximately 18.6% of the MassHealth Pharmacy budget.

In continuing our focus on quality of care, patient safety, and cost considerations, and after careful consideration and discussion with experts and advocates, the MassHealth Pharmacy Program and the Department of Mental Health have jointly agreed that certain changes to the MassHealth Drug List are appropriate. The new requirements will adhere to evidence-based practice while simultaneously helping to control the cost of the second generation antipsychotics. Many second generation antipsychotics are, or soon will be, available generically. With the generic availability of clozapine, risperidone, olanzapine, quetiapine, and ziprasidone, members have access to a wide variety of second generation antipsychotics with varying potencies, receptor targets, and side effect profiles that provide a broad and flexible approach to the treatment of the major psychiatric disorders for which these drugs are indicated.

The changes that will be made to the MassHealth Drug List are described below.

Starting on June 4, 2012, the MassHealth Drug List will be changed to reflect the following:

Generic atypical antipsychotics including clozapine, olanzapine, quetiapine, risperidone, and ziprasidone will be available without prior authorization (PA). The existing quantity limits and polypharmacy rules will continue to apply.

Long-acting injectable medications will continue to be available without PA (existing quantity limits and polypharmacy rules apply).

New PA requirements for Abilify® (aripiprazole), Seroquel XR® (quetiapine extended-release), Invega®, Fanapt®, Latuda®, and Saphris® will apply, as described below:

·	For schizophrenia and other primary psychotic disorders, bipolar disorder, autism spectrum disorders, and psychotic depression
o a trial of 2 different atypical antipsychotics at an adequate dose is needed.
·	For all other diagnoses
o a trial of 2 different antidepressants and 2 different atypical antipsychotics at an adequate dose is needed.

All members currently stable on any atypical antipsychotic (based on MassHealth claims data) will be grandfathered for the life of the member if they remain on that medication and consistently refill it. Stability is defined as MassHealth paid claims indicating the member has received 90 days of medication in a 120-day time window. This is a method that MassHealth has used with previous initiatives for many therapeutic classes in the past to ease potential disruption in therapy.

We would like to thank you for continuing to work with us to help promote high quality care while reducing unnecessary costs. We will continue to post updates on our progress on the MassHealth pharmacy Web site at www.mass.gov/masshealth/pharmacy, and send written communications as needed.

Sincerely,

Paul L. Jeffrey, PharmD	Debra A. Pinals, M.D.
Deputy Director	Interim Deputy Commissioner
Office of Clinical Affairs	Clinical and Professional Services
Director of Pharmacy	Massachusetts Department of Mental Health
MassHealth