Antipsychotics & State Lawsuits: Stallard Explains
39 CommentsBy Ed Silverman // September 15th, 2008 // 2:18 pm
More states are filing lawsuits against drugmakers over allegations they failed to disclose side effects caused by their antipsychotics and improperly marketed the pills, therefore, causing state Medicaid programs to overpay for the medications. Meanwhile, many of these same state programs have been paying for antipsychotic prescriptions for unapproved uses in children, such as ADHD. We spoke with David Stallard, a special assistant attorney general in Utah, which sued Eli Lilly last year, about a state’s view of the problem…
Pharmalot: How’d you get involved in this litigation?
Stallard: I was working as an assistant attorney general for about five years and, most of that time, I was working in the Medicaid fraud control unit, spending a large part of my time, almost exclusively the last two years, on civil medicaid fraud, specifically, pharmaceutical fraud with respect to Medicaid.
Pharmalot: There’s that much fraud?
Stallard: There’s a lot of fraud. These are pretty intensive cases and take a lot of time. My opinion it’s because Medicaid drugs are such a huge part of the business for pharmaceutical companies and it’s very attractive market - feeding at the taxpayer trough. I’m kind of a skeptic having worked in the trenches, but pharmaceutical companies try to get as much reimbursement as they can from Medicaid, because it’s a big payer. And not just on price, but utilization. As many pills as they can, and the highest price they can engineer.
Pharmalot: Why did Utah sue Lilly?
Stallard: Utah has chosen to sue on behalf of its state Medicaid program only two companies for what I call failure to warn - risks we allege were known early on by the company but concealed - Merck’s Vioxx and Lilly’s Zyprexa. In my opinion, there was a common theme. If they got what was going to be a blockbuster, they focus on the positives, but not give the FDA the negatives. And they would also train reps to dodge questions from docs. Separately, there was pricing fraud - overcharging medicaid - they falsely inflated list prices to First Databank and other compendia relied on by Medicaid and other third-party payors for medicaid reimbursement prices.
But with Lilly specifically, there was a lot of off-label use that was promoted by Lilly improperly. It’s actually illegal under Federal Food Drug & Cosmetic Act. But under state law, we’re claiming Lilly improperly marketed the drug and caused us to pay more than we should have.
Pharmalot: But there was another issue raised, right?
Stallard: Yes, and in fact, I wrote a memo that has to do with a second component - medically accepted indications for proper use. My legal analysis of federal Medicaid law is that, in order to be eligible for Medicaid reimbursement, the drug must be covered outpatient drugs. It’s basically a threshhold requirement. There is a limitation on the definition of covered outpatient drugs that is tied to use of drug and it does not include ‘a drug or biological used for a medical indication which is not a medically accepted indication.’
Pharmalot: So you’re saying, under that definition, a state Medicaid program shouldn’t be paying.
Stallard: To me, it means that to be eligible for reimbursement for Medicaid - to be a covered outpatient drug - it has to be used for a medically accepted indication. Under that provision, it’s not a covered outpatient drug unless its used for a medically accepted indication. It’s not just a term of art. It’s specifically defined in the federal statute. It has to be FDA approved for use or supported by specific compendia.
Pharmalot: But some state officials tell me a drug is covered because docs can prescribe off label.
Stallard: That’s a separate issue. Just because doctors prescribe, doesn’t mean Medicaid can pay for it. In order to get federal funding, Medicaid programs must comply with federal law. It’s not just indication - it’s also dosage and age range of patients.
Pharmalot: Florida is an example where there’s controversy over antipsychotics given kids with ADHD.
Stallard: I think they shouldn’t be experimenting when it’s never been tested on children. It’s a big mistake. Sometimes, legislators say they need to be liberal with vulnerable segments of society to give them medicines that may have some benefit. I turn it around and say we shouldn’t be experimenting with the most vulnerable segments of our society.
Pharmalot: But how does a state monitor every single doctor and prescription?
Stallard: Legally, they should be monitoring. Practically speaking, I have to admit it’d be virtually impossible for a state Medicaid program to monitor this for every single drug. Some have prior authorization requirements. Most state Medicaid programs trust the chart. If something comes to their attention - a particular drug or class of drug - they may look at it more closely. I think it’s true the states aren’t doing this, and frankly, I sympathize with them because I agree it’d be a herculean task, but legally that seems to be what congress is saying.
Pharmalot: So where does this leave us?
Stallard: It should leave us here - state Medicaid programs should be aware of their costliest drugs and drugs known to cause serious adverse events and put them higher on the radar. And atypical antpsychotics meet both criteria - they’re expensive and cause a lot of problems. With certain classes they probably ought to be doing that, and comply with federal law. Each state is going to have to decide. The Center for Medicare & Medicaid hasn’t been much of a policeman enforcing the law. But states should enforce it with respect to the most troublesome drugs.
Daniel Haszard
Zyprexa has generated a lot of bad press for Eli Lilly and they still have unresolved Zyprexa settlement claims.
Eli Lilly is ‘reaping the whirlwind’ for aggressive marketing of Zyprexa that has caused suffering and deaths.
Zyprexa is being avoided by doctors they aren’t prescribing it for new patients anymore.
–
Daniel Haszard Zyprexa patient who got diabetes from it.
Dan A.
Nice informative interview that illustrated a very devastating fact, which is that there is frightening autonomy in regards to drug dispensing and regulation- Medicaid or otherwise.
A reminder that medicaid is specifically for the poorest of the poor. To steal this from them could be considered a rather grave sin.
Most societies in the world take care of the weak and those in need if ill. We seem to capitalize on thier conditions. We meaning those who place prosperity over the well being of others with a ‘I got mine, so you get yours’ mentality.
Apologies for the homily, but it’s an opinion of mine.
Salmon
Zyprexa
Approved 1996
Marketed 1997
Current Sales ~$4.7 Billion / year
Total Sales so far $40 - $50 Billion
Increased sales of Lilly Diabetes Meds Hundreds of millions / Billions ?
Likely costs of inappropriate use - Unknown. few hundred millions or even billions.
Likely Lilly Assessment. It’s worth it!
Answer: Significant Criminal Penalites (decades) and Significantly punitive Monetary Penalties (they shouldn’t remain multimillions) for the officers and the board of directors. Disbarment from pharmaceutical industry.
Salmon
Medicaid Pharmacy Director
I am a pharmacy director for a managed medicaid plan and perhaps can shed some additional light to this situation:
Managed Care plans for the most part are very aware of the off-label problems related to antipsychotics and ADHD medications. In many cases, we try to employ various utilization management controls in order to ensure that they are used for their FDA-approved use. These might include things such as Prior Authorization, Age limits, dosing limits, and polypharmacy edits.
Unfortunately, in many states the regulatory agencies involved (in essence our employers) impose various restrictions in the way managed care plans can implement these important tools. In some cases, it is because there is legislation in place that requires open access, or carte blanche to certain types of prescribers (i.e, psychiatrists). I should tell you that the majority of off-label prescribing comes form this very group of prescribers that get open access. Usually this legislation comes about because advocacy groups (such as NAMI) or pharma do a very good job of convincing state politicians to enact laws so that there are no restrictions in place. My personal belief is that in order to allow the best management in both the state medicaid Fee-for-service side, as well as managed medicaid, that someone needs to look long and hard at some of this legislation that has been enacted.
Lisa Van S
Ed,
It’s a shame he didnt look into GSK’S Paxil for kids.
A.G. Stallard can look here:
http://www.paxilharmschildren.com
Jack2
…It has to be FDA approved for use supported by specific compendia.
Does anyone have a copy of the actually law. I ask because he seems to follow a much stricter interpertation than anything else I’ve heard. I’ve always heard the interperatation FDA approved OR one of a specific handful of compendia. To point out the misinterperation of the rule, if you really needed both (compendia + FDA approval) you’d really only need one (FDA approval), so why mention compendia at all.
Lisa Van SSRI: you are aware that antipsychotics are a different class of meds than SSRIs? I ask because you seem well informed on some aspects, but keep dragging SSRIs into every thread when there’s no mention of SSRIs. Or do you just like advancing your agenda?
Sam
To the Medicaid Pharmacy Director:
Mr Stallard states: “To me, it means that to be eligible for reimbursement for Medicaid - to be a covered outpatient drug - it has to be used for a medically accepted indication. Under that provision, it’s not a covered outpatient drug unless its used for a medically accepted indication. It’s not just a term of art. It’s specifically defined in the federal statute. It has to be FDA approved for use supported by specific compendia.”
I am a database programmer and have put together the FDA Black Box Warnings related to pediatric use of psychiatric drugs and compiled the Medicaid payments for such drugs, a few of which tables include the patient age.
You can see these listings at http://www.psychdrugdangers.com/NotApprovedForPediatricUse.html
and in the Medicaid Drug Uses & Payments menu pulldown links.
The Black Box Warnings for many of these drugs unequivocally say: “This drug is not approved for use in pediatric patients.”
And you can see in the Michigan and New Jersey Medicaid payment tables that Medicaid has paid for these drugs prescribed to pediatric patients.
In the US Medicaid Summary tables which are compiled from the Center for Medicare & Medicaid Services data, an estimated $6.9 BILLION dollars (12% of the total, estimated from the Michigan and New Jersey known pediatric Rx’ing) have been paid for pediatric Rxs for psychiatric drugs that are either explicitly not FDA-approved for pediatric use on their Black Box Warning labels or are only approved for specific indications.
Can you explain to me why the State Medicaid Agencies justify or are required to make these payments when the drugs are clearly not approved for pediatric use?
Doing so seems to conflict with Mr Stallard’s (and my) view.
Sam
Jack2,
Re SSRIs:
See http://www.psychdrugdangers.com/NotApprovedForPediatricUse.html
Many SSRIs are likewise not approved for pediatric use or are only approved for specific indications. Paroxetine (Paxil) is one of the SSRIs that is in the “not approved for pediatric use” Black Box Warning camp yet is frequently so prescribed as can be seen in the Oct 2006 New Jersey Medicaid Reimbursements table at http://www.psychdrugdangers.com/NJ/NJMedicaidOct2006.html (which is also linked in the Not Approved for Pediatric Use page).
Citalopram and Escitalopram are also “not approved for pediatric use” by the FDA and yet have been so prescribed as evidenced by the New Jersey October 2006 Payments table and the Michigan 2005 Payments table at http://www.psychdrugdangers.com/MI/MichiganMedicaid2005.html which shows payments for these SSRIs and for the atypical antipsychotics mentioned in this article.
Lisa Van S
Jack2,
Actually,.. its the FDA who brings this issue to light,.. It was the FDA who placed an antidepresssant Black Box Warning on the antipsychotics Abilify and Seroquel. FDA monitors this sight, so maybe we can all ask them to elaborate more specifically on the issue… Yes?
Medicaid Pharmacy Director
Sam,
I can not explain why these choose to make payments for those uses but can offer a few guesses:
1. To impose restrictions (prior auths, age/dose limits,etc) requires administrative and clinical support. Someone has to review the Prior Auth requests or handle phone calls. The state medicaid agencies simply don’t have enough internal staff to administer. Their focus is more on the claims payment side, rather than clinical management.
2. Often the state medicaid agencies enter into supplemental rebate agreements with manufacturers to obtain rebtes beyond what they get from the federal medicaid rebate program. Typically in order to get that extra rebate, manufacturers not only require preferred formulary positioning, but relatively unhindered access as well.
Medicaid Managed care plans have more internal administrative and clinical staff to manage those medications to ensure they are used safely. Often, they will do so despite not qualifying for rebates, in the name of safety and appropriate use. I think that if many of the laws/procedures for limiting utilization controls on behavioral health meds were re-visited, you would see managed medicaid taking a more active role in making sure these drugs are used safely.
Dan A.
Upon analysis, the FDA historically implements addressing the concerns of certain drugs only when they have to due to pressure, instead of doing what they should, which is to act immediately if a drug is suspected of being harmful to others. The FDA has been known to refer to pharmaceutical companies as ’sponsors’ or ‘clients’. This suggests collusion if not cronyism. And people are harmed due to thier lack of urgency. Increasing thier staff recently, as read in about every media outlet, was to pacify the citizens, in my opinion. Reality bites.
Jack2
Lisa: Abilify and Seroquel have thost BBWs because they have indications in depression. That still doesn’t make them SSRIs.
Dan: You take issue with the term “sponser?” A person who vouches or is responsible for a person or thing?
Lisa Van S
Jack2,
“Abilify and Seroquel have thost BBWs because they have indications in depression.” HUHHH?? Got me stooped!! Care to explain!!!
You need to do your homework, You look very foolish here.!!
Sam
Medicaid Pharmacy Director,
Thanks for the answer.
Here’s what I don’t get:
The FDA Black Box Warnings state “this drug is not approved for pediatric use.” That means (to me) that it’s not approved for pediatric use NOW, and I haven’t seen anything (and I think you might be hard-pressed to show) that these drugs have EVER had FDA approval for pediatric use. So how could there be a “prior authorization”?
And I know about “off label” use. As Mr Stallard points out, this is an entirely different issue and really has nothing to do with whether Medicaid reimburses an Rx or not; Medicaid payment is a matter of it being an FDA-approved (or not) drug for an FDA-approved (or not) indication.
Rather I think - and of course I could be wrong as I don’t deal with this as closely as you do - that “prior authorization” here probably means absolutely nothing more than “we have paid for such claims in the past”.
It wasn’t FDA-Ok for them to be reimbursed in the past, but somehow the claim slipped through and was paid which established (the only) “prior authorization” for paying them now.
In particular, the atypical antipsychotics are not now and never have been approved for ADHD and yet this is a common (if not the most common) indication for pediatric prescribing and they are paid for in the millions of dollars, such as the Florida claims with ADHD as an indication, which is not now and never has been an approved indication for atypical antipsychotic drug treatment. So why does Florida (and New Jersey, and Michigan, and probably every other State) continue to pay for them?
No, I don’t believe that there is any “prior authorization” for many of these pediatric Rx Medicaid payments; I think they are being paid simply and only because “we paid them before and no one is explicitly telling us NOT to pay for them now.”
Can you show me one? What is the reference (other than “we paid for a claim like this last month”) for payment? Does a reimbursement claim ever come through and Medicaid says “no”?
I asked my State Medicaid agency (New Jersey) what authorization they had to make these types of payments and got stonewalled, no answer.
And even if one of these drugs has a “prior authorization”, how can that overturn a CURRENT “this drug is not approved for pediatric use” statement.
After all, the current pediatric patient being prescribed these drugs NOW with Medicaid claims for reimbursement being submitted NOW was not being prescribed them (perhaps wasn’t even alive) when the “prior authorization” was in effect THEN, was he or she?
So how is “prior authorization” even an argument?
I can agree that such “prior authorization” justifies payment back then, but not now.
Aside from (although in large part because of) the fact that these drugs are dangerous and do a great deal of harm to those taking them as reported to the FDA in countless Adverse Reaction reports, what makes me particularly mad about this is that this is MY money that Medicaid is spending without FDA authorization.
Medicaid is fully funded by State and Federal taxes. This is not some nebulous fund, this is MY tax dollars, this is OUR tax dollars (and no one elses dollars) being spent in this medical experiment on our children.
The FDA says “these drugs are not approved for pediatric use.” And there are thousands of reports filed annually listing thousands of severe adverse reactions experienced by children (and others) taking these drugs.
For an agency (the FDA) that seems to bend over backwards to please the pharmaceutical companies to come out with a clear-cut “this drug is not approved for pediatric use”, that statement means to me “this drug is REALLY not approved for pediatric use.”
Are the Medicaid Agencies simply paying ALL Medicaid claims because they have been submitted by an authorized entity (such as a psychiatrist), or are there some that they refuse to pay because the drug is not approved for pediatric use and/or the submitted indication regardless of who submitted the claim?
I would like an accounting of what I and all the other taxpayers paid for. I would like to see what we didn’t pay for because a Medicaid employee was on the ball, doing his/her job.
It is my (our) money they (Medicaid) spent. Why can’t they tell me what I bought? And if they paid for something on my behalf that the FDA has stated is “not approved for pediatric use”, how did they justify that spending?
And if they can’t come up with an explanation other than “it’s what we’ve ALWAYS done” (and I would be surprised if they can give another explanation), then don’t they owe me (us) a refund? Or, at the very least, to please STOP DOING IT!
And the rebates you mention: isn’t that just some of my tax money not being spent when NONE of it should have been spent in the first place?
Seriously, look at http://www.psychdrugdangers.com/US/MedicaidPsychDrugPayments.html
in the Percent of Yearly Totals section: there has been a 4,772% increase in spending for psychiatric drug prescriptions since 1991; a $22.7 BILLION dollar increase in spending since 1991. And in http://www.psychdrugdangers.com/US/MedicaidPsychDrugPayments.html you can see that the atypical antipsychotics have been responsible for 37.44% of the $99.7 BILLION total dollars spent on psychiatric drugs; the SSRIs were second with a 16.2% share.
Don’t these huge sums of your (our) money spent for no visible result (where are the mentally well kids?) make you as a taxpayer a little mad?
Jack2
Lisa: Here’s the atypical antipsychotics: clozapine, risperidone, olanzapine, quetiapine, ziprasidone, aripiprazole, paliperidone.
Of those, two have indications in depression (aripiprazole, quetiapine).
Of those, two have the BBW related to pediatric suicide (aripiprazole, quetiapine).
Do you think there’s a relationship. Like…if you get the indication you get the BBW.
Also NONE of these drugs are SSRIs (which is how I let myself get drawn into this conversation in the first place).
Jack2
Sam: Prior authorization means the drug is not automatically reimbursed at the pharmacy. Usually it means that if a doc wants to write a script for the PA drug they have to write the script AND fill out a form to fax to the form to the insurance company (or Medicaid) about why they should cover that script. It’s an added hurdle for the prescriber to overcome.
What do different stake holders think of PA? Probably, prescribers find it annoying. Probably, pharma tries to avoid getting a prior authorization on their drug because it makes using the drug inconvient. Probably, the insurance company does it when they feel that a more expensive brand name drug will not provide much greater benefit for most patients compared to a different generic drug.
David Stallard
To clarify applicable federal Medicaid law [42 U.S. Code 1396r-8(k)(3)&(6)], drugs are “covered outpatient drugs” eligible for Medicaid reimbursement ONLY IF used for “medically accepted indications,” which is clearly defined as either an FDA-approved use OR a use “supported” in one or more of 3 specific prescription drug compendia:
(I) American Hospital Formulary Service Drug Information;
(II) United States Pharmacopeia-Drug Information (or its successor publications); and
(III) the DRUGDEX Information System
[42 U.S. Code 1396r-8(g)(1)(B)(i)]
Jack2
Thank you for clarifying your comment: It has to be FDA approved for use supported by specific compendia.
Lisa Van S
Jack2,
You are correct that these meds are not ssri’s, but they carry the BBW. I was informed by an FDA official, that the reason
For the BBW is that when used off-label the SSRI BBW applies. Congress is looking into this because the label is confusing. Lots of folks are scratching their heads on this one.
Perry
No, not FDA approved for use supported by specific compendia.
It is FDA approved OR supported in one of the drug compendia
Perry
Pharmalot did an article about New Jersey antipsychotic Medicaid funding for kids here:
http://www.pharmalot.com/2008/02/nj-legislator-probe-antipsychotics-kids-medicaid/
Check out Abilify. $15.9 million paid by New Jersey Medicaid. When was Abilify approved for anything with children? 2008? Therefore NJ Medicaid is violating Medicaid rules and should get back all that money.
Sam
Perry,
Exactly, but not it’s not just New Jersey:
For all patient ages, New Jersey Medicaid has paid $56,174,950 for Abilify (aripiprazole). The $15.9 million that you cite (for pediatric) is 28% of that.
Nationally all States paid out $2,609,649,911 for Abilify (aripiprazole).
A conservative 20% of that is $522 Million; 28%, using the NJ percentage, is $730 Million.
And it’s not just Abilify:
Nationally all State Medicaids paid out $37,347,017,695 ($37.3 Billion) for Atypical Antipsychotic Rxs.
20% of that is $7,469,403,539; 28% is $10.4 Billion.
Sam
Jack2,
Thanks, I understand the “PA” concept now.
I would like to see what the psychiatrist who got a PA for one of the atypicals he/she prescribed for pediatric ADHD wrote that convinced someone at Medicaid that the Rx should be reimbursed despite the fact that those drugs are not approved for ADHD or other indications.
Sam
Mr Stallard,
Thanks for clarifying “covered outpatient drug”.
I believe that many of the Medicaid reimbursements for psychiatric drugs, both atypical antipsychotics and other classes, such as SSRIs, have been made where the drug is not a “covered outpatient drug”.
As I said to Jack2, I’d like to see what a reimbursement claimant (such as a psychiatrist) could write to Medicaid to convince Medicaid to reimburse for a drug that is explicitly “not approved for pediatric use”, or where the indication, such as ADHD, is not now and never has been an approved indication for atypical antipsychotic drug treatment.
I would not be at all surprised to find that Medicaid is approving such reimbursements simply and only because the PA request “came from a psychiatrist”.
As you say, this is nothing more than experimenting with our youth under the vague hope that this or that psychiatric drug will have some beneficial effect when time after time the actual result is injury or death.
Why should taxpayers foot the bill for this experiment if it’s for a a drug that is not covered?
atlex
All,
FDA approval is not the only mechanism for making a drug coverable under Medicaid. Federal law mandates that Medicaid programs also cover unapproved indications that are cited in certain compendia. I don’t know whether this is the case for the use of anti-psychotics in pediatrics, but I suspect that there is enough literature regarding such use that the compendia do list this indication. If there is such a listing in the compendia, all a physician would likely have to do is cite the compendia and meet the other components of the PA (eg, step therapy).
Atlex
Perry
Atlex,
Understood it is not just FDA approved. It is FDA approved or SUPPORTED by a citation in the compendia. Not just listed in the compendia.
There is no supporting citations at all for using these antipsychotics for ADHD.
Perry
Sam,
Do you have any exact dollar amounts for kids on the antipsychotics instead of just
estimates?
Lisa Van S
Atlex,
I have to admit that I have a lack of understanding here. Would TMAP or CMAP be considered a compendia.
atlex
Lisa,
The law actually defines three compendia:
* American Hospital Formulary Service-Drug Information (AHFS–DI)
* American Medical Association Drug Evaluations (AMA–DE)
* United States Pharmacopoeia-Drug Information (USP–DI)
Unfortunately, I think 1 of these no longer exists or one other is no longer accepted. However, CMS also has the discretion to revise this list and, subsequently, developed a process for doing so. I’m not sure where this stands.
I can say that something along the line of TMAP and CMAP would not qualify as compendia.
By the way, Perry is correct that an off-label use must be supported in the compendia, not just listed. I sort of assumed that folks would understand that.
Atlex
Perry
Lisa,
As Mr. Stallard stated these are the 3 drug books (compendia - plural of compendium):
American Hospital Formulary Service Drug Information
United States Pharmacopeia-Drug Information (or its successor publications)
the DRUGDEX Information System
So simply - for reimbursement to take place, the use of a drug must be supported in one of those books OR must be approved by the FDA.
Lisa Van S
Atlex and Perry,
Thank You, I apreciate the two of you taking the time to explain this to me.
Jack2
Atlex: Pharmacopeia no longer counts. It changed a bit and the new version is not accepted.
Perry
I think there’s a typo in this interview:
I believe the word “for” should be “or”:
“It’s specifically defined in the federal statute. It has to be FDA approved for use supported by specific compendia.”
Jack2
That still wouldn’t really work. It would need to be:
It’s specifically defined in the federal statute. It has to be FDA approved for use OR supported by specific compendia
truthman30
I find this whole anti-psychotic scam nauseating ..
I know a few people who have been prescribed anti-psychotics and none of them were “psychotic” .. (actually they they were all very good people, just being human)
One friend was a bit moody, so they diagnosed her with bi-polar, and prescribed an anti-psychotic..
Another was angry , mostly just pissed off with his job and his life situation, he was offered an anti-psychotic, but thankfully he declined ..
Another guy I know was having trouble with deciding what to do with his life, his parents wanted him to go to college, he wanted to busk and play his guitar, they had a row, his parents drag him to a psych and he gets prescribed Risperdal for a year, had awful side effects like tremors and tics.. He came off it, thank god, and he does yoga now to balance out his energyand calm him down.. he doesn’t need meds, he never needed them.. he was just duped like a lot of people are…
Do people not realize that the anti-psychotics are just another pharmaceutical-psychiatric scam?..
It is just another way for them drug emotions and feelings..
Is you’re too happy, you must be manic!
If you’re sad, you must be clinically depressed!
If you’re shy, you’ve got generalized anxiety disorder..
If you’re moody and sensitive, you’re Biploar!
If you’re losing the plot because the world is crapping on you from a height… you must be psychotic!
Psychiatry has the whole spectrum of human emotions almost covered now..
They are despicable , but if there is anything thing I do admire about psychiatrists it is their audacity and their amazing ability to pull of scam after scam …
They are the snake oil merchants of our times..
They laugh their way to the bank while the patients bawl their way to the morgues..
Surreal..
Sam
Perry,
I have exact dollar amounts for Michigan for 2005 at http://www.psychdrugdangers.com/MI/MichiganMedicaid2005.html which is for all psychiatric drugs, and the exact amounts for New Jersey for antipsychotics in the Pharmalot article at http://www.pharmalot.com/2008/02/nj-legislator-probe-antipsychotics-kids-medicaid/.
Sam
Jack2 (or anyone else),
Can you explain to me how the Medicaid payment claim line works?
Say a pediatric patient comes to a pharmacy (with a parent or guardian, of course) with an Rx for Abilify. The Indication was ADHD, but that’s not written on the Rx (I assume).
What steps does the pharmacy go through to get reimbursed by Medicaid? Or does it get pre-authorization from Medicaid before dispensing the drug? Or does it go ahead and dispense the drug because the patient is covered by Medicaid and then worry about reimbursement?
When and to whom does the psychiatrist need to explain why he/she prescribed Abilify for ADHD for which Abilify is not and never has been covered? Does the Indication ever come up?
It would seem that in a case like this that pre-authorization from Medicaid would need to be obtained before dispensing the drug. And since Abilify is not covered for ADHD, it would seem that the drug should never get dispensed, and yet it does over and over again.
Who’s dropping the ball? It seems it would be someone in Medicaid who is approving the claim for a drug that is not approved for the Indication and has never appeared in a compendium for that use.
Sam
Perry,
P.S. - the Michigan and New Jersey pediatric Medicaid Rxs that I mentioned are an average 12% of the CMS total (all patient ages) for these States, that’s why I use 12% as a pediatric estimate for the other States on the http://www.psychdrugdangers.com/US/MedicaidPayments.html State listings.
harpy
Truthman, you’ve reminded me of a joke I heard last year:
What were the names of Snow White’s seven dwarfs after being prescribed Paxil, Ritalin, Prozac, Lithium, Provigil and Benadryl?
Dwarf, Dwarf, Dwarf, Dwarf, Dwarf, Dwarf and Doc.