The Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid 600 Washington Street Boston, MA 02111 January 2010 Dear Colleague, The Massachusetts Department of Mental Health and the MassHealth Pharmacy Program would like to provide you with an update to our letter of April 2009, regarding behavioral health medications. We wish to inform you of some additional steps the MassHealth Pharmacy Program will be taking as it continues to focus on quality of care, patient safety, and cost concerns regarding these medications. We are pleased to report that the growth of new prescriptions among the atypical antipsychotics appears to have flattened out since our April communication (see Chart I). Unfortunately, over the same period, prices for these medications have increased at unprecedented rates (see Chart II) and offset our collaborative efforts to reduce expenditures. In April’s letter we recommended interventions to reduce simultaneous prescribing of multiple antipsychotic and other behavioral health medications, and the utilization of generic therapies when appropriate. Behavioral health medications continue to account for nearly $190 million, or 37% of the total MassHealth pharmacy budget. Atypical antipsychotics represent over $93 million, or 18.5% of the annual pharmacy costs. Prior Authorization for Antipsychotics MassHealth currently requires prior authorization (PA) for the use of multiple concurrent antipsychotic medications and for antipsychotic medication prescriptions in excess of established quantity limits. In addition, after careful consideration, MassHealth will require PA for specific atypical antipsychotics as described below. We also intend to require PA for new behavioral health drugs that do not show substantial evidence of superiority over currently available medications. We believe this reasonable, incremental approach to behavioral health drug management minimizes risk to our members while maintaining the integrity of the MassHealth Pharmacy Program. The following changes to the MassHealth Drug List will become effective for prescriptions dispensed on or after March 1, 2010. 1. Saphris (asenapine) and Fanapt (iloperidone) will require PA. Saphris and Fanapt do not have demonstrated superiority over currently available antipsychotics. Authorization for the medications will be based on the outcome of a therapeutic trial of a generic atypical antipsychotic and two other antipsychotics. 2. Invega (paliperidone) tablets will require PA for MassHealth members who are not currently taking Invega on a continuous basis, defined as maintaining a possession ratio of 75% (i.e., refilling prescriptions 90 of every 120 days). Invega will not require PA for MassHealth members who are currently taking Invega tablets on a continuous basis, according to the DEVAL L. PATRICK Governor TIMOTHY P. MURRAY Lieutenant Governor JUDYANN BIGBY, M.D. Secretary - 2 - above criteria. Invega does not have demonstrated superiority over currently available antipsychotics. Authorization will be based on the outcome of a therapeutic trial of a generic atypical antipsychotic and two other antipsychotics. 3. Invega Sustenna (paliperidone palmitate) will not require PA. Risperdal Consta will continue to be available without PA. This decision is based upon the expectation that good clinical practice will have demonstrated that oral paliperidone or oral risperidone, respectively, is effective for the patient and that the patient has then shown the need for the long acting dosage form. Quantity limits will be imposed to prevent inadvertent excessive dosing. Update on Low-Dose Seroquel The MassHealth Pharmacy Program has relaxed quantity limits for zolipidem, flurazepam, temazepam, triazolam, and estazolam to allow 30 tablets for 30 days without prior authorization. This change is a direct result of your feedback following our November 2009 letter regarding low-dose Seroquel. Please see the enclosed letter for further information on the management of chronic insomnia. In conclusion, we appreciate your collective response to our communications as well as your individual feedback. The Department of Mental Health and the MassHealth Pharmacy Program leadership are committed to an ongoing dialogue and collaboration with you. Please continue your efforts on the following recommendations. 1. Reduce the use of brand-name antipsychotics by starting or, when appropriate, changing patients to generic therapies. Because millions of people have taken older generic drugs, more is known about their risks and side effects. Generic drugs are often safer than newer, brand-name (and expensive) drugs. The full side effect profile of new drugs may not be fully recognized until years after a drug first comes to the market (e.g., metabolic syndrome). 2. Reduce the simultaneous prescribing of two or more atypical antipsychotics for the same patient. 3. Reduce the use of four, five, six, and even seven behavioral health medications for the same patient at the same time. Concomitant medications for medical indications compound the risk to our members. We will continue to provide you with updates of pharmacy expenses by category at www.mass.gov/druglist. If you have additional suggestions for advancing high quality, cost-effective care for MassHealth members who require behavioral health medication, please e-mail us at masshealthdruglist@state.ma.us. We appreciate your continued efforts to ensure that all of our MassHealth members are provided medically necessary prescriptions. Sincerely, Mary Ellen Foti, MD Paul L. Jeffrey, PharmD Deputy Commissioner for Clinical & Deputy Director, Office of Clinical Affairs Professional Services Director of Pharmacy Department of Mental Health MassHealth - 3 - Chart I: Number of Claims0200040006000800010000120001400016000May 09Jun 09Jul 09Aug 09Sep 09Oct 09Nov 09Dec 09SeroquelRisperidoneAbilifyZyprexaGeodonInvega Chart II: Average Cost Per Claim$0$50$100$150$200$250$300$350$400$450May 09Jun 09Jul 09Aug 09Sep 09Oct 09Nov 09Dec 09ZyprexaAbilifyInvegaGeodonSeroquelRisperidone