Within the private sector, the MCOs interviewed believed that PA is required less often for psychotherapeutics than for other drug classes. Based on the above review of formularies, presented above, it appears that PA for a specific antidepressant may be somewhat more common than for a specific statin, although PA for obtaining access to any newer antidepressant is not any more common. Three of the MCOs interviewed made all antidepressants and antipsychotics available without PA. One MCO interviewed required PA for venlafaxine and nefazadone. Approval of these requests required documentation of a treatment failure with a first-line agent, typically an SSRI.
The PBMs interviewed reported that prior authorization programs are rare. When they exist, they typically are designed at the request of an MCO or employer client. The PBMs interviewed indicated that PA is required for psychotherapeutics no more frequently than for other drug classes. One PBM indicated that PA was probably most common in anti-infectives, where there was a need to reserve many newer agents for treatment-resistant strains of bacteria. Some PBMs attempt to integrate PA with physician education and monitoring of appropriate care. For example, one PBM is in the process of instituting a prior authorization program for all behavioral health pharmaceuticals on the formulary if the prescription exceeds the FDA-recommended dose. Safety and efficacy were named the prime factors for justifying PA. Primacy care physicians or psychiatrists initiate such a request. Employer or MCO clients may specify additional PA approval criteria. Staff pharmacists of the PBM usually review the request with or without the consultation of a staff physician. Decisions take approximately 24 hours by phone or fax through an automated system.
The employer-sponsored health plans interviewed do not operate prior authorization programs for psychotherapeutic drugs. These employers report that they do not see the value in prior authorization. In fact, one employer eliminated their prior authorization program at their employees' request. Instead, this employer now educates physicians about cost-effective prescribing. The current trend appears to be toward open formularies, with management of "lifestyle" drugs (e.g., drugs for migraine, erectile dysfunction) via quantity limits or higher co-payments. Otherwise, employers are rarely involved in the management of the utilization of individual drugs.