OMH Seeks Examples of Medicaid Medication Access Problems

Hello Colleagues,

NYS Office of Mental Health is participating with NYS Medicaid to improve parts of the Medicaid Managed Care and Fee For Service pharmacy programs.  As part of our efforts, we need to provide some examples to the committee.  Please help us to improve the process by providing specific patient examples for the following stakeholder reported problem scenarios via email to Dr. Molly Finnerty (Molly.Finnerty@omh.ny.gov) and Catherine Benham (Catherine.Benham@omh.ny.us) before close of business on Tuesday June 12th:

1.      Medicaid Fee-for-Service formulary seems “eccentric” and differs from each of the Medicaid HMO formularies, which in turn differ from each other.     Some of the examples already provided by stakeholders are the inclusion of flurazepam, temazepam, and chloral hydrate on the preferred drug list (PDL) for Medicaid FFS, the absence of trazodone from the PDL for Medicaid FFS, the inclusion of Saphris, and others.

2.      Many practitioners have decided to change their prescribing patterns to medications that do not require a PA, even though it is not the best treatment for the patient.     An example already submitted was using risperidone or olanzapine when the preferred choice was aripiprazole to avoid weight gain / cardiometabolic side effects because it was the preferred agent and did not require prior approval.

3.      It is a barrier to access to care because physicians have to spend so much time on the phone. A quarter of clinical time is spent on the phone with insurance companies. 

4.     Formularies are too restrictive with regard to drugs commonly used by child psychiatrists.     An example that has been provided by stakeholders is the need for prior authorization for medications they considered first line including long acting stimulants, Strattera or Intuniv.

5.      Inconsistent denial criteria and inappropriate justifications for alternative recommended (i.e.: requested drug not clinically indicated and suggested alternative also not clinically indicated)

6.      Quantity limit information incomplete

7.     Waive PA and titration when child treated in residential setting, under the close supervision of physician when Dr. provides: explanation of supervision, why med was chose, symptoms being target and role of drug in comprehensive treatment plan

8.      Need a standardized step therapy policy for Child & adolescents for previously exempt categories, including fair and adequate trial periods across plans

9.      Develop Child &Adolescent prescribing protocols by symptom, multi-disorders

10.  Inappropriate dosing or quantity limits i.e.: pediatric titration, step therapy.  One of the examples given was that pediatric dosing follows the “start low, go slow” approach and so may be blocked as a sub-therapeutic dose by such limits.

11. Gaps between MCO & FFS formularies and treatment practices in residential treatment facilities (RTFs have all inclusive Medicaid rate and no formulary)

 

 

We appreciate your assistance to improve the process!

 

Catherine Benham, RPh, MS

Pharmacy Services Director

NYS Office of Mental Health

catherine.benham@omh.ny.gov

518-474-7720