Most PBMs track and monitor drug utilization. The majority of DUR programs run through PBMs are retrospective only (although two PBMs run concurrent DUR). They are either managed in-house or through the main health plan. Quality assurance is the most important goal of DUR, followed by formulary compliance (and reduction of drug costs). DUR is ofte
HCFA(now known as CMS) performs drug utilization analysis on an ad hoc basis for the mental health therapeutic classes. The findings of HCFA(now known as CMS)'s reviews are not for public distribution. All Medicaid and State Mental Health Agencies perform some type of drug utilization review, in accordance with the requirements OBRA '90.
Access and Utilization of New Antidepressant and Antipsychotic Medications. C. Utilization Management
Health care payers have turned to utilization review (DUR) as a primary means of quality assurance and cost-containment. All of the payers interviewed maintain some form of utilization review program. DUR monitors providers, identifies outliers (i.e., over/under-prescribers), and screens patients (e.g., high cost cases eligible for disease managem
Manufacturers devote considerable effort to marketing psychotherapeutics to physicians, although tactics vary. For example, both Janssen and Eli Lilly maintain a specialized detail force for mental health, whereas SmithKline Beecham promotes paroxetine largely through a non-specialty force. AstraZeneca promotes quetiapine through a generalized sal
Access and Utilization of New Antidepressant and Antipsychotic Medications. Clinical Development and Trial Design
The clinical trials submitted for review to the FDA by the manufacturer determine the indications for which a drug may be marketed. Although trials used to obtain approval may be sufficient to convince regulatory authorities that a new drug is safe and effective, their design may or may not be adequate to convince health care payers that a new dru
Access and Utilization of New Antidepressant and Antipsychotic Medications. Special Population Guidelines
The New York State department of Corrections currently administers treatment algorithms and guidelines for the treatment of mental illness. The primary goals of these programs are to provide the highest level of care combined with some level choice to individuals with mental illness.
Access and Utilization of New Antidepressant and Antipsychotic Medications. Private Sector Guidelines
Several health care payers and health maintenance organizations have produced more explicit guidelines for the choice of antidepressant and antipsychotic medications. These range in scope from designations of preferred medications to more comprehensive sets of guidelines for the management of these illnesses.
Access and Utilization of New Antidepressant and Antipsychotic Medications. Public Program Guidelines
The Health Care Financing Administration(now known as Centers for Medicare and Medicaid Services(CMS)) does not in general instruct States on the choice of individual pharmaceutical agents for inclusion in formulary or treatment guidelines. However, HCFA(now known as CMS) has sent a letter to State Medicaid Directors urging the coverage of atypica
The AHCPR depression guidelines, published in 1993, describe a range of issues to be considered in the selection of a pharmacological therapy for depression. These guidelines specify that one of the SSRIs available at the time of publication (fluoxetine, sertraline, and paroxetine), bupropion, trazadone, or a secondary amine TCA (e.g., notriptylin
Access and Utilization of New Antidepressant and Antipsychotic Medications. A. Treatment Guidelines and Preferred Medications
Guidelines for the treatment of schizophrenia, depression and other mental disorders have been produced by various sources. By and large, however, these have been the products of individual health plans, health service programs, or professional associations.
Access and Utilization of New Antidepressant and Antipsychotic Medications. Chapter V. The Current State of Antidepressant and Antipsychotic Utilization
Although newer antidepressant and antipsychotic medications were much more readily available to health care consumers in 1999 than they were when first introduced, health care payers have been less aggressive at promoting appropriate use than they had been at discouraging inappropriate use. Primary research indicated few cases where payers have im
A principal finding of this study is the absence of traditional step care protocols, whereby patients are required to try an older generation agent prior to obtaining approval for reimbursement of a newer one. This situation represents a shift from the situation several years ago, where trial of either a tricyclic antidepressant or a typical antip
Prior authorization does not generally operate in the New York State corrections system. Off-formulary drugs are theoretically available in the IHS via prior authorization. Any physician can make a PA request. The staff pharmacists and clinical directors at the central area office review these requests. A decision is returned in three working days
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
HCFA(now known as CMS) has no statutory or regulatory authority over States' PA programs, provided that therapeutic alternatives are available without PA. However, HCFA(now known as CMS) has some authority over process issues. For example, in response to complaints from advocacy groups on PA programs that were too active and involved cumbersome pa
The provider and consumer associations interviewed reported that formularies are no longer impeding access to newer medications. This view has been confirmed by the research presented above. These groups felt that prior authorization and paperwork requirements were now the primary barrier to access. The four associations interviewed reported that
Access and Utilization of New Antidepressant and Antipsychotic Medications. The Formulary Status of Newer Antidepressant and Antipsychotic Medications
Newer antidepressant and antipsychotic medications have attained formulary status in most of the programs surveyed in this study. Although most payers provide for the coverage of at least several of the newer agents first-line, not all payers cover every newer agent without prior authorization.
Access and Utilization of New Antidepressant and Antipsychotic Medications. Factors influencing the formulary decision
The formulary decision-making process ranges from a relatively simple administrative process to a complex review of the efficacy and economics of a therapeutic class, depending on the payer type and the individual benefit package.