Newer antidepressant and antipsychotic medications were much more readily available to health care consumers in 1999 than they were when first introduced. Primary research indicated few cases where newer agents were either not reimbursed or older agents were designated as preferred first-line agents. Notably, many respondents indicated that the removal of restrictions (e.g., demonstrating failure first on conventional therapy) was a relatively recent policy change. In this section, we report on the status of access as assessed in our research.
In summary, this study found:
Health care payers almost always cover psychotherapeutics as part of a general pharmaceutical benefit. As such, most health care payers provide coverage for psychotherapeutics on an equal basis with other drug classes and do not apply special restrictions to antidepressants or antipsychotics as general classes. Specifically, psychotherapeutics as a class are not generally:
- Financed separately from the general pharmaceutical benefit;
- Subject to lower maximum benefit levels, higher levels of cost sharing, or more restrictive number of prescriptions;
- Covered so differently between treatment settings or payers that continuity of care is compromised; or
- Subject to rigid prescriber credentialling processes.
New generation antidepressants and antipsychotics are widely included on health plan formularies. Few formularies completely exclude newer psychotherapeutics. However, not all formularies include every new generation antidepressant and antipsychotic agent.
- Most formularies include at least three new generation antidepressants and at least one new generation antipsychotic.
- Informants surveyed indicated that psychotherapeutics are not subject to more rigorous formulary review than are other classes of drugs. These is some evidence that psychotherapeutics are evaluated less stringently.
- The inclusion of new-generation antidepressants and antipsychotics on many health plan formularies is a relatively recent change from previous policy.
Prior authorization is a more common utilization control than is formulary exclusion.
- Antipsychotics are largely free of prior authorization requirements at the policy level. These requirements may be imposed at the local level.
- Prior authorization is more frequently required for antidepressants because
- These agents have a higher potential for misuse; and
- These agents are used by a much larger section of the population and therefore represent more important targets for utilization control.
Step care protocols whereby treatment failure on generic agents is required before a patient is allowed access to new generation agents appear to be largely in the past.
Each of these issues is discussed in further detail below.