Manufacturers, providers and consumers concur that formularies are no longer restricting access to newer psychotherapeutic agents
- Closed formularies are maintained by 8 State Medicaid programs (California, Colorado, Hawaii, Illinois, Michigan, Montana, Ohio, and South Dakota). All HCFA(now known as CMS)-approved drugs are covered if Prior Authorization (PA) is obtained.
- Only California appears to severely restrict the choice of pharmaceutical agents available without PA.
- None of the State Mental Health Systems interviewed for this study exclude any of the newer antidepressant or antipsychotic medications from coverage.
- Formularies were used by over 75% of HMOs in 1997, up from less than 50% in 1990. At the same time, physicians appear to have increasing influence over the choice of medications included on the formulary.
- Employers do not generally get involved with the specifics of formulary management. Most of the employers interviewed stated that they had open formularies.
- The formularies of the New York State prison system and the Navajo Region of the Indian Health Service are closed. These programs most aggressively pursue switching of patients from non-formulary to formulary drugs.
The concept of "open, closed, or restricted" formulary is changing in meaning and is not an accurate depiction of access.
- In 1997, 33% of plans used formularies described as "closed."
- Often, closed formularies allow non-formulary drugs to be reimbursed if prior authorization is obtained.
- Closed formularies are being replaced by "preferred" drug lists, whereby physicians are encouraged, but not required, to prescribe a particular drug.
- In 1997, 52% of plans used formularies described as "selective" or "partially closed."
Plans with closed formularies may take active steps to enforce the formulary. These may include:
- Physician profiling;
- Claim lockouts;
- Withholding physician bonuses; and
- Imposing financial penalties.
Effectiveness and cost are the most frequently cited barriers to formulary approval. The relative importance of each of these factors depends on the class of drugs and particular interest of an individual health plan.
- Any drug for which the manufacturer has entered into a rebate agreement with HCFA(now known as CMS) is eligible for inclusion on Medicaid formularies.
- There are only 10 exceptions, mostly barbiturates and benzodiazepines.
- Medi-Cal, on the other hand, has a more complex method of approving drugs for formulary inclusion. These criteria were published in a journal article describing the information needs for this purpose.6 In addition, Medi-Cal makes available its criteria for formulary review.
- Private health care payers maintain pharmacy and therapeutics committees that review formularies on a regular basis. These committees are made up of physicians, pharmacists, and administrators.
- Employers do not maintain their own P&T committees, but work with their MCOs and PBMs to design a formulary suitable to their needs.
Newer antidepressant and antipsychotic medications have attained formulary status in most of the programs surveyed in this study.
- Most payers cover at least two of the four SSRIs approved in the US for the treatment of depression (fluoxetine, paroxetine, citalopram, sertraline), and at least one other new antidepressant (venlafaxine, nefazadone, bupropion).
- Most payers cover at least one of the new-generation antipsychotics.
- The private sector has embraced the newer agents, although formularies appear to be more actively managed than in the public sector
- The formulary status of the newer antidepressant and antipsychotic agents is consistent with the pattern observed for other classes of branded pharmaceutical agents.