Access and Utilization of New Antidepressant and Antipsychotic Medications. Limits on Prescription Coverage and Cost Sharing Requirements


Consumer associations and pharmaceutical manufacturers report that psychotherapeutics often are subject to higher copayments or lower total cost caps than are other classes of drugs. Our research has not validated this concern. It is clear that the copayments required for branded drugs are universally higher than those required for generics, but this differential applies to all branded drugs, regardless of indication.

  1. Public Programs

    No differences in cost sharing between psychiatric drugs and other drug classes exist in any of the Medicaid programs interviewed. Differences do exist between the copays required for branded and generic drugs. Co-payment requirements within Medicaid pharmacy benefit programs are regulated by Federal statute. In 1997, 17 States required no co-payment for prescription benefits, whereas co-payments ranged between $0.50 and $3.00 in the remaining programs. Co-payments for pharmacy benefits within Medicaid managed care programs are regulated by the waiver operating in that State and vary from plan to plan.19

    Currently, 12 State Medicaid programs (Arkansas, California, Florida, Georgia, Mississippi, Nevada, New York, North Carolina, Oklahoma, Texas, West Virginia, Wyoming) limit the number of prescriptions per patient per month, while all but two States (Indiana and Iowa) place limits on the number of refills per prescription or the quantity that can be dispensed at any one time. Restrictions on the number of prescriptions range from 10 per year (West Virginia) to 6 per month (several States). States that impose limits most commonly limit recipients to either 3 or 6 prescriptions per month.19 These prescription limitations apply regardless of therapeutic class. Several States interviewed recognized that these limitations can pose problems for patients with other illnesses requiring frequent prescriptions, and indicated that often these restrictions can be worked around by "staggering" the filling of different prescriptions from month to month. For example, Wisconsin limits recipients to three prescriptions per month. However, maintenance medications can be dispensed in 90-day supplies. In contrast, none of the State Mental Health programs reported any limitations on the number of prescriptions that could be dispensed to any one beneficiary in a given month.

    The DoD and the VA do not require co-payment for prescriptions if the prescription is dispensed from a DoD or VA facility pharmacy. If the prescription is dispensed at a non-DoD or VA pharmacy, a nominal co-payment is required, ranging between $2 and $9. The level of copayment is set based on whether the drug is a branded or a generic drug. Drug class does not affect copayment.

  2. Private Payers

    None of the private insurers interviewed reported restricting the number of prescriptions reimbursed per recipient. However, individual plans may have annual limits on the dollar amount reimbursed. This limit applies to all pharmaceuticals and is not selectively applied to psychotherapeutics. Similarly, private sector insurers do not demand higher copayments for psychotherapeutic agents than they do for other drug classes. Most plans require a higher copayment for branded drugs than they do for generics. Therefore, because the newer psychotherapeutic agents do not have generic equivalents available, there mayappear to be a difference between the copayment required for these newer psychotherapeutics than is required for many "physical health" drugs.

    The "three tiered copay" is a new method of cost sharing being introduced by many health care payers. These arrangements are causing increasing concern among both consumers and pharmaceutical manufacturers. Whereas "classical" copayment systems require a higher copayment for a branded products than for generic ones (e.g., $10 brand, $5 generic), these new copay systems create 3 groups: generic, "preferred brand," and "non-preferred brand." The designation of "preferred" and "non-preferred" is not simply a statement of superior drug efficacy. Rather, drugs are grouped into these categories based on a complex decision made by the MCO that considers a range of issues including efficacy, safety, therapeutic duplication, use and abuse potential, cost and cost-effectiveness. The specific rationale for placing any specific drug in one of these tiers is generally regarded as a trade secret. The ability of the MCO to negotiate contracts with pharmaceutical manufacturers likely plays a role in this process, although no MCO or manufacturer was willing to discuss this issue.

    Under one proposed system for Blue Choice (Rochester, NY area), copayments for generics would range between $2 and $10, preferred brands between $12 and $25, and non-preferred brands between $30 and $40. These copayment levels reflect a marked change from the previous "nominal" copayments. In most of these three-tiered systems, individual new generation antidepressants and antipsychotics appear in both the "preferred" and "non-preferred" categories. Although, many of the newer psychotherapeutics are classified as "non-preferred," there does not appear to be any "singling out" of psychotherapeutics as a class for higher copayments. Indeed, several popular antibiotics, antihistamines, statins, and calcium channel blockers are placed in the non-preferred class.20

  3. Special Populations

    Neither the New York State corrections system nor the Indian Health Service requires cost sharing of its recipients.