Access and Utilization of New Antidepressant and Antipsychotic Medications. Pharmaceutical Benefits


Pharmaceutical benefits are commonly available for psychotherapeutic agents.

  • Most health care payers interviewed covered pharmaceuticals to at least some degree.
    • Employers offer pharmaceutical benefits as part of comprehensive health insurance. Employers work with carriers to design benefits, but rarely become involved in the details of individual drug coverage.
    • Behavioral Health Managed Care Organizations rarely become involved with the administration of pharmaceutical benefits and therefore exercise only limited influence over these.
  • Psychiatric medications are usually covered as part of the general pharmaceutical benefit; rarely are these carved out from the general benefit.
  • Pharmaceutical benefits are financed by a mix of capitated and fee-for-service arrangements, although fee-for-service appears to be regaining popularity.
  • Although consumer advocacy organizations claim that psychotherapeutics are covered at a lower level than other medications, this research found no evidence to support this claim at the administrative level.

Limits on prescription coverage and cost sharing requirements apply equally to all classes of medications.

  • Consumer associations and pharmaceutical manufacturers contend 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.
    • Copayments required for branded drugs are universally higher than those required for generics. Therefore copayments required for new generation psychotherapeutics are usually higher than those required for generic medications of any class.
  • None of the Medicaid programs interviewed require different cost sharing for psychiatric drugs compared to other drug classes.
    • Copayment requirements differ only by whether the drug dispensed is a branded drug or a generic drug.
    • 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.
    • 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.
  • Within the private sector, limits and cost-sharing requirements are applied equally to all drug classes.
    • None of the private insurers interviewed restrict the number of prescriptions reimbursed per recipient.
      • Individual plans may have annual limits on the dollar amount reimbursed. This limit applies to all pharmaceuticals and is not selectively supplied to psychotherapeutics.
    • None of the private insurers 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.
      • Several plans are moving to "three tiered copay" whereby different copayments are required for generics, drugs designated by the payer as "preferred brands", and drugs designated "non-preferred brands." The designation "preferred" and "non-preferred" is one made by the health care payer and reflects a complex (and usually proprietary) assessment of issues including efficacy, safety, therapeutic duplication, use and abuse potential, cost, and cost-effectiveness. Within several plans examined, new generation psychotherapeutics do not appear to be forced wholesale into the "non-preferred" group. Rather, the preferred group usually includes a selection of several new generation antidepressants (typically 3 or 4) and antipsychotics (typically at least 2), with the balance of the group being placed in the third tier.
  • State programs were unaware of any problems with continuity of care between treatment settings.
  • State programs were unaware of any systematic differences between the pharmacy benefit coverage between Medicaid and State Mental Health programs.
    • These often work off the same formulary and route purchases through the same channels.
  • The DoD and VA reported no systematic problems insuring the continuity of care between inpatient and outpatient settings.
    • The VA has established procedures to insure a patient is managed consistently when discharged from an inpatient setting.
  • Private payers uniformly report that access to psychotherapeutic agents is no different between inpatient or outpatient settings.
    • Most MCOs make allowances for a new enrollee to continue treatment on non-formulary drugs started while insured by another payer.
  • The issue of prescriber credentialling largely applies to antidepressants.
  • Many payers are concerned about inappropriate use of antidepressants for purposes other than the treatment of depression. Restrictions on the prescription of these agents by primary care physicians are designed to avoid misuse.
  • Most providers and payers agree that prescription of antipsychotics by primary care physicians is not medically appropriate.