WellCare and Long-Acting Injectable Antipsychotics

WellCare and Long-Acting Injectable Antipsychotics

January 27, 2017

The discovery and development of atypical antipsychotics has unequivocally improved the quality of life for people living with schizophrenia. Atypical antipsychotics like aripiprazole, brand name Abilify, and paliperidone, brand name Invega, have been clinically shown to be effective in the treatment of schizophrenia. Assuming patient adherence, these medications dramatically reduce the symptoms of schizophrenia, thus reducing the occurrence of relapse and hospitalization.

Patient adherence is a major obstacle in treating schizophrenia and schizoaffective disorder, as well as other chronic, severe mental illnesses. Poor adherence may be the single biggest factor in the ineffectiveness of treatment for schizophrenia. Long-acting injectable antipsychotics like Abilify Maintenna and Invega Sustenna have been shown to be effective in improving patient adherence. This improved adherence leads to better health outcomes, and a decrease in relapse and hospitalization.

Managed Care Organizations, or MCOs, provide for the delivery of Medicaid health benefits. There are five different MCOs that manage the delivery of Medicaid health benefits in the state of Kentucky: Aetna, Anthem, CareSource, Passport, and WellCare. Each of these MCOs has covered the long-acting injectable antipsychotics Abilify Maintenna and Invega Sustenna, until now. WellCare has opted to no longer include these clinically effective medications on their Preferred Drug List (PDL).

WellCare has stated that their decision to no longer include Abilify Maintenna and Invega Sustenna has been made for “psychoeconomic reasons”. Psychoeconomics, also called behavioral finance, is a rather jargony term that simply means “economics” as applied in the behavioral health field. It is another way of them saying that the removal of Abilify Maintenna and Invega Sustenna from their PDL is an economic decision, one made without the consideration of health outcomes for patients who take these medications.

WellCare has stated that patients who currently take these medications will be “grandfathered in” indefinitely. “Indefinitely” is a term that can be interpreted as being for as long as the patients desire, implying a commitment to continuity of care, but it is a non-binding term that simply means that they will be covered until an unspecified date.

WellCare has stated that they value transparency, and yet they use amorphous language like “psychoeconomics” and “indefinitely” in describing this change in formulary. Their stated reasons for this change in formulary have been ambiguous at best. This is the opposite of “transparency”.

While WellCare will continue to include some long-acting injectable antipsychotics in their PDL, these medications are not interchangeable. What works for one patient may not work for another. The decision as to what medications are most effective for treating specific patients should be made by doctor and patient, not by WellCare.

WellCare is an MCO based in Tampa, not Kentucky. The decision as to which long-acting injectable antipsychotics they will include in their PDL is being made in a Tampa office that is concerned primarily with WellCare’s bottom line and shareholder concerns, not with the effectiveness of the treatment of patients in Kentucky. Ironically, this decision will likely hurt WellCare financially in the long run, as the increase in relapse and patient rehospitalization will probably prove to be more costly than simply covering these proven, clinically effective medications. This does even not include the human cost, as ineffective treatment not only leads to relapse and hospitalization, but also leads to a dramatic increase in the risk for patient death by suicide.

This change in formulary will have a dramatically negative impact on health outcomes for people living with schizophrenia in Kentucky. It is not hyperbolic to say that it will even cost lives. And it will do so for no other reason than that it may, not will but may, improve WellCare’s bottom line in a rather insignificant way.

Mental Health America of Kentucky is working with WellCare to address these issues. If you know anyone who is affected by the new formulary please contact us at 859-684-7778 or by email at mhaky@mhaky.org.