PROVIDENCE -- To save money in the state's Medicaid program by encouraging the use of less-expensive generic drugs, Rhode Island may be jeopardizing the health of its mentally ill residents, mental-health advocates say.

The General Assembly authorized the state Department of Human Services to create a preferred drug list that would limit the drugs covered by Medicaid. The DHS sought public feedback on implementing that and other new laws in a hearing last week. Advocates for the mentally ill responded in force, pleading with the DHS to exclude mental-illness medications from the new regulations.

A preferred drug list could have a "devastating" effect because it would "force physicians to choose medications that they otherwise would not prescribe," Chaz Gross, executive director of the National Alliance on Mental Illness-Rhode Island, said at the hearing.

Providence resident Charles Feldman said he tried four different antipsychotic medications before finding one that worked. That drug has enabled him to hold a job for the last seven years, he said. "Would you prefer that people like me go back to the hospital . . . and lose their jobs if they can't get prior authorization for a medication that works?" Feldman, 54, asked DHS officials.

More than a dozen other states have already enacted preferred drug lists. The lists save money in three ways:

They compel people to use generic drugs when available.

If no generic alternative exists, the list will include the least costly brand-name alternative.

If two or more brand-name alternatives are comparable in cost, a preferred drug list may still confer savings because all Medicaid recipients will use one drug, instead of two or more different drugs. Because Rhode Islanders are buying more of one drug, the state may be able to negotiate a quantity discount with the drug manufacturer. The new law also authorizes Rhode Island to participate in multistate pools to get quantity discounts.

The state budget assumes implementing the list will save $1.6 million in state general revenues, and $4.5 million overall -- including federal money -- this fiscal year, on a program whose annual cost is $27.7 million in state general revenues, and $58.5 million overall.

The budget article authorizing the preferred drug list specifically exempts three classes of drugs: antipsychotics, antiretrovirals and organ-transplant medications. At the hearing, Gross requested that the state also exempt antidepressant, antianxiety and anticonvulsive drugs from the new rules.

DHS Director Ronald A. Lebel says the list, which the department is developing in conjunction with the University of Rhode Island School of Pharmacy, will focus first on medications for high blood pressure and elevated cholesterol levels, and that limiting doctors' and patients' choice among drugs that treat mental illness isn't a goal.

Another law change also has mental-health advocates worried: for the first time this year, those who get prescriptions through Medicaid must pay a copay -- $1 for each generic, and $3 for each brand-name.

That may not sound like much, but many people with mental illness require a treatment regimen of multiple drugs -- commonly between five and eight prescriptions, testified Elizabeth Earls, president and CEO of the Rhode Island Council of Community Mental Health Organizations.

The new rules don't apply to the elderly who get medication through Medicare Part D drug plans, or to people enrolled in RIte Care, the state's subsidized health-insurance program for the poor (although RIte Care is financed in part with federal Medicaid funds). Rather, the rules apply to about 20,000 low-income Rhode Islanders in the so-called fee-for-service Medicaid program -- 6,000 children with special health-care needs, 13,500 disabled adults, and 500 seniors who aren't eligible for Medicare.

Because preferred drug lists reduce the overall cost of government, the AARP, which represents the interests of older Americans, generally supports such lists, said Barbara Peters, spokeswoman for the AARP of Rhode Island.

Peters called preferred drug lists "a very good cost-containment tool." But she said it's important that the lists are based on sound science, and that the appeal process isn't overly burdensome. "There are cases where only the brand-name drug will do," Peters said.

The new law says doctors may dispense "72-hour emergency supplies" of drugs "if authorizations cannot be obtained."

It says the DHS will approve a drug not on the list if a doctor can certify that:

The alternative on the preferred drug list "has failed to produce the desired health outcomes."

The patient has tried the alternative on the preferred list and the drug produced "unacceptable side effects."

The patient's condition has responded to a drug not on the list, and changing drugs "would be medically contraindicated."

It also seems to give doctors the final say. The law says, "If after consultation with [the DHS], the prescriber, in his or her reasonable professional judgment, determines that the use of a prescription drug that is not on the preferred drug list is warranted, the prescriber's determination shall be final."

Mental-health advocates still oppose subjecting psychotropic drugs to the list, as does the pharmaceutical-industry lobby -- which opposes the list altogether.

The list will clearly cut into drug companies' profits. But it may also imperil patients' health, said Julie Corcoran, deputy vice president for state policy with the Pharmaceutical Research and Manufacturers of America.

"Fundamentally, we believe that all individuals should have access to all medicine," Corcoran said. "Anything that interferes with the doctor-patient relationship, we oppose."

egudrais@projo.com / (401) 277-7045