Access and Utilization of New Antidepressant and Antipsychotic Medications. Prior Authorization


Provider and consumer associations interviewed report that prior authorization and paperwork requirements are now the primary barrier to access.

  • These groups contend that prior authorization is required more for mental health pharmaceuticals than other drugs.
  • These groups also contend that paperwork requirements to obtain PA are unduly burdensome.
    • The present research suggests that PA is becoming increasingly automated and that this trend is adding efficiency to the process.

Antipsychotics no longer require prior authorization as a matter of policy. However there are some restrictions at the facility (community) level. PA may be more common for antidepressants.

  • State Medicaid programs may require PA only when therapeutic "equivalents" exist.
    • HCFA(now known as CMS) has the authority to monitor and regulate the process of obtaining PA and determine whether processes are unduly burdensome.
  • Prior Authorization for antipsychotics is relatively rare within the private sector.
    • PA is implemented at the request of the client to the company administering pharmaceutical benefits.
    • PA is required no more frequently for psychotherapeutics than it is for other classes of pharmaceuticals
    • The trend in private insurance appears to be towards open formularies with more active management of "lifestyle" drugs (e.g., drugs for migraine, erectile dysfunction) via utilization controls.