New Medicaid drug list brings changes

An extensive list of preferred drugs for use in Maine’s Medicaid program became effective Monday. Under the new list, many drugs formerly available to MaineCare patients will be off-limits until less expensive medications are shown to be ineffective.

For instance, according to the list, before the state will pay for the drug Nexium to treat gastric reflux, a patient and doctor must first try four other medications. Prilosec, an even more expensive product to treat the condition, can only be prescribed after six other medications have been ruled out.

The change also includes an out-of-pocket co-payment of $2.50 for each medication with a monthly cap of $25. The charge replaces an earlier co-payment of between 50 cents and $3 with no cap.

The preferred drug list was developed by negotiating rebates from drug companies. Manufacturers offering the most savings find their products among those that can be prescribed most easily.

The state will use the unusual method to reduce Medicaid costs without dropping any of the program’s approximately 210,000 enrollees. The list is expected to save taxpayers about $100 million over the next two years, according to the state’s Department of Human Services.

In some circumstances, explained Newall Augar, a spokesman for DHS, a physician may bypass the approval system by making a case to the department for the medical necessity of a particular medication. And some drugs in use by some patients may be “grandfathered” – particularly in the case of psychiatric medications, which can be especially difficult to manage and devastating to change.

Augar said DHS has notified physicians, pharmacists and MaineCare enrollees of the changes.

Bill Miller, owner of Miller Drug in Bangor, said most of his MaineCare customers seemed unconcerned about the changes on Monday, especially since the state has allowed pharmacists to partially fill existing prescriptions until doctors can either rewrite them or get approval through DHS.

But many MaineCare patients will have to make changes in their drug regimens, and physicians will shoulder an additional administrative burden as a result of the new list.

Gordon Smith, director of the Maine Medical Association, called the preferred drug list “awful.” According to Smith, the list is not only labor intensive for prescribers but also imposes restrictions on “off-label” uses – acknowledged uses of certain medications to treat conditions for which they’re not specifically approved.

For example, Smith said, the antipsychotic drug Zyprexin is effective in controlling the delusions of Alzheimer’s patients but does not have FDA approval for that use. MaineCare will not pay for its use in Alzheimer’s patients.

Still, Smith said, physicians understand that the state was “between a rock and a hard place” in finding a way to balance the current budget without dropping MaineCare enrollments or raising taxes, as Gov. John Baldacci had pledged to do. The governor’s new Dirigo Health plan promises to increase MaineCare enrollments even further, Smith noted.

“If they’re going to keep bringing people in [to Medicaid] they’re going to have to go through a process like this,” Smith said. “Unfortunately, doctors and patients are caught in the middle.”

Maine is one of just four or five states to implement a preferred drug list to hold down Medicaid costs, according to Augar. The list requires federal approval, which has been received.