State Medicaid officials this summer will place a cap on the amounts and types of prescription narcotics and antidepressants that patients can receive without their doctors justifying it to officials.

It's a closely watched move aimed at curbing demand for the public health program's most abused — and costly — medications.

Starting Friday, Medicaid will stop covering all name-brand antidepressants, including Prozac, Zoloft and Celexa, without a doctor's express justification. Then on Sept. 1, physicians also will have to get approval before treating Medicaid patients with more than one similar antidepressant, even generics, beyond 68 days.

Separately, on July 11, Medicaid will start electronically flagging the records of patients who exceed 10 prescriptions of narcotics in a month. Pharmacists won't be allowed to dispense the painkillers — except to cancer patients — unless the prescribing doctor gets authorization from the state.

The changes are a part of the state's efforts to reduce the volume of drugs and medical services, and curb inappropriate care. Washington was among the first and most aggressive at promoting cheaper generics and to restrict emergency-room "frequent flier" patients to a single physician to coordinate their treatments.

Emergency-room doctors hail the crackdown on excessive narcotic prescriptions, and one doctor even argues the new rules aren't tough enough.

But the proposed restrictions on antidepressants are drawing concerns from some physicians and mental-health advocates, who fear that psychiatric patients may face delays in getting their medication or may not get it at all.

In 2003, a similar move to shift Medicaid patients to generic narcotics triggered so many appeals from doctors and patients that the state temporarily suspended the policy.

Medicaid officials say the changes are more about good medicine than money. "We're not against paying for psychiatric medications. We want to pay for the right medication," said Siri Childs, Medicaid's chief of pharmacy policy.

The most immediate change for Medicaid patients is Friday's adoption of a preferred-drug list for antidepressants. Doctors will no longer prescribe name-brand antidepressants for patients on Medicaid. Instead, they must choose one of five "preferred" generic alternatives.

And doctors must provide a medical justification if they want to prescribe a non-preferred drug.

The five generic options include versions of such name-brand antidepressants as Prozac and Paxil. But the generic versions of other antidepressants, such as Effexor, are not on the state's list.

And the preferred-drug list does not include all formulations of a single drug, which may affect a patient's dosage.

For instance, Medicaid will pay for the generic version of Wellbutrin. But it will cover only the "regular release" formula, which patients must take twice a day; it won't pay for the one-a-day formula.

That's a worry to child psychiatrists, said Dr. Sharon Farmer, a psychiatrist and a medical director for the King County Department of Community and Human Services. Extended-release pills are important for children because they don't have to take them at school, and for people who forget to take their pills, "which is a lot of people," she said.

In the past four years, Washington's Medicaid program has adopted preferred-drug lists for 15 other classes of prescription medication, predominantly generics.

The preferred-drug list applies to more than 400,000 Washington residents who are covered under Medicaid's traditional fee-for-service plan.

The state also plans next year to extend the preferred lists to antipsychotic drugs and drugs for attention-deficit disorders, said Dr. Jeffrey Thompson, Washington's Medicaid medical director.

But the National Alliance for the Mentally Ill (NAMI), an advocacy group based in Arlington, Va., opposes any constraints on psychiatric drugs, calling it "a dangerous proposition." People who are schizophrenic, bi-polar or depressed need access to drugs with minimal interference, the group argues.

In fiscal 2004, Washington spent $489 million on Medicaid pharmacy benefits, up 10 percent from 2003, with the largest share going to psychiatric drugs. Schizophrenia drugs accounted for three of the most expensive. State officials are also scrutinizing Medicaid databases for duplicate prescriptions for psychiatric drugs. The state has identified about 1,000 people who currently are taking at least two similar antidepressants.

Medicaid officials are urging doctors to treat patients with one antidepressant until they reach the maximum dose before switching to another drug.

After Sept. 1, patients can not stay on two or more antidepressants after 68 days unless doctors have gotten special "prior authorization" from the state.

Dr. Thompson, the Medicaid medical director, said the rule is for both safety and cost. Combining Zoloft, Luvox and other antidepressants can cause adverse reactions. Yet most doctors don't know whether their patients are receiving multiple prescriptions, Thompson said.

Still, Dr. Charles Huffine of the Washington State Psychiatric Association said he worries the new rule will hurt patients who need a mix of drugs to manage depression.

"One antidepressant may not do the job," Huffine said.

If the state requires prior authorization, the pharmacist must contact the state, which contacts the prescribing physician for an explanation, a process that can take a day or more. The state gives doctors the final say, but a 2002 study by NAMI in Florida found that a third of patients who were turned away because they had no prior authorization never received their medication, Thomspson said.

Doctors can bypass the prior-authorization process by signing a pledge to become an "endorsing provider," which gives them the authority to instruct pharmacists to dispense the prescriptions as written. But only 40 percent of the 13,500 Washington doctors who participate in Medicaid have done so.

In contrast, the new rules restricting access to narcotic painkillers have wide support

State officials say they have identified about 320 Medicaid patients who have gotten more than 10 prescriptions for narcotics a month. The prescriptions were written by 2,600 different doctors, and the state last month warned the doctors about those patients.

Barring an emergency, once a Medicaid patient hits the 10-prescription limit, pharmacists will be electronically notified that they cannot dispense the narcotics until the prescribing doctor faxes a form to the state to ask for a waiver.

Dr. Cynthia Wolfe, director of Emergency Services and Chief of Medicine at Capital Medical Center in Olympia, said drug-seeking patients waste doctors' time and tie up emergency-room beds. So she favors the new rules because people seeking narcotics under false pretenses has become a crisis.

One narcotics prescription typically lasts a month, so Wolfe contends that a legitimate pain patient would rarely need more than two prescriptions in 30 days.

At 10 prescriptions, "they're talking about major, major abuse," Wolfe said.

Kyung Song: 206-464-2423 or ksong@seattletimes.com.