Access and Utilization of New Antidepressant and Antipsychotic Medications. Pharmaceutical Benefit Design

01/01/2000

Benefit design is the primary mechanism that influences access to newer pharmaceuticals. Some health plans do not cover pharmaceutical benefits at all (e.g., Medicare), while others place restrictions on the number of prescriptions a given beneficiary may receive each month (e.g., several State Medicaid programs). Furthermore, coordination of benefits between inpatient and outpatient, access to specialty psychiatric care, and payment responsibility represent three ways in which benefit design can affect access. Based on our review of the literature and on previous research, we identified the following issues as factors that primarily impact benefit design:

  • Coverage of pharmaceuticals;
  • Financing methods;
  • Limits on the number of prescriptions reimbursed per month and whether these are different for psychiatric drugs than for other drug classes;
  • Cost sharing requirements for pharmaceuticals and whether these are different for psychiatric drugs than for other drug classes;
  • Continuity of care between inpatient and outpatient settings;
  • Coordination of benefits among different payers;
  • Access to specialty psychiatric care; and
  • Prescriber credentialling.