Article Abstract

Article Abstract

Online ISSN: 1099-176X Print ISSN: 1091-4358
The Journal of Mental Health Policy and Economics
Volume 18, Issue 3, 2015. Pages: 165-173
Published Online: 1 December 2015

Management of Newer Antidepressant Medications in U.S. Commercial Health Plans

Dominic Hodgkin,¹* Constance M. Horgan,² Timothy B. Creedon,³ Elizabeth L. Merrick,⁴ Maureen T. Stewart⁵

¹Ph.D., Professor, Institute for Behavioral Health, Schneider Institutes for Health Policy, Heller School of Social Policy and Management, Brandeis University, Walthan, MA, USA
²Sc.D., Professor Institute for Behavioral Health, Schneider Institutes for Health Policy, Heller School of Social Policy and Management, Brandeis University, Walthan, MA, USA
³M.A., Research Assistant Institute for Behavioral Health, Schneider Institutes for Health Policy, Heller School of Social Policy and Management, Brandeis University, Walthan, MA, USA
⁴Ph.D., MSW, Senior Scientist Institute for Behavioral Health, Schneider Institutes for Health Policy, Heller School of Social Policy and Management, Brandeis University, Walthan, MA, USA
⁵Ph.D., Scientist Institute for Behavioral Health, Schneider Institutes for Health Policy, Heller School of Social Policy and Management, Brandeis University, Walthan, MA, USA

* Correspondence to: Dominic Hodgkin, Heller School of Social Policy and Management, Brandeis University, Waltham, MA 02454, USA.
Tel.: +1-781-736 8551
Fax: +1-781-736 3985
E-mail: hodgkin@brandeis.edu.

Source of Funding: This study was funded by the National Institute on Drug Abuse (grant R01 DA 029316), and the National Institute on Alcohol Abuse and Alcoholism (grant R01 AA 010869).

Abstract

In the US, private insurers use various approaches to restrain pharmaceutical utilization and costs, particularly for newer and costlier medications. This paper studies which approaches health plans were using in 2014 for six of the newer brand antidepressant medications, using data from a nationally representative survey of commercial health plans. Very few plans excluded any of the six antidepressants studied, although many used other types of restrictions. Medications were more likely to be subjected to restrictions if they were newer, more expensive or were reformulations. 55% of health plan products used placement on a high cost-sharing tier (3 or 4) as their only form of restriction for these newer branded antidepressants. Plans have increased their use of prior authorization and step therapy for newer antidepressants since 2003. Most of these medications had generic equivalents that offered at least some substitutability, reducing access concerns somewhat.

Background: Private health insurance plays a large role in the U.S. health system, including for many individuals with depression. Private insurers have been actively trying to influence pharmaceutical utilization and costs, particularly for newer and costlier medications. The approaches that insurers use may have important effects on patients' access to antidepressant medications.

Aims of the Study: To report which approaches (e.g., tiered copayments, prior authorization, and step therapy) commercial health plans are employing to manage newer antidepressant medications, and how the use of these approaches has changed since 2003.

Methods: Data are from a nationally representative survey of commercial health plans in 60 market areas regarding alcohol, drug abuse and mental health services in 2010. Responses were obtained from 389 plans (89% response rate), reporting on 925 insurance products. For each of six branded antidepressant medications, respondents were asked whether the plan covered the medication and if so, on what copayment tier, and whether it was subject to prior authorization or step therapy. Measures of management approach were constructed for each medication and for the group of medications. Bivariate and multivariate analyses were used to test for association of the management approach with various health plan characteristics.

Results: Less than 1% of health plan products excluded any of the six antidepressants studied. Medications were more likely to be subjected to restrictions if they were newer, more expensive or were reformulations. 55% of products used placement on a high cost-sharing tier (3 or 4) as their only form of restriction for newer branded antidepressants. This proportion was lower than in 2003, when 71% of products took this approach. In addition, only 2% of products left all the newer branded medications unrestricted, down from 25% in 2003. Multivariate analysis indicated that preferred provider organizations were more likely than other product types to use tier 3 or 4 placement.

Discussion: We find that U.S. health plans are using a variety of strategies to manage cost and utilization of newer branded antidepressant medications. Plans appear to be finding that approaches other than exclusion are adequate to meet their cost-management goals for newer branded antidepressants, although they have increased their use of administrative restrictions since 2003. Limitations include lack of information about how administrative restrictions were applied in practice, information on only six medications, and some potential for endogeneity bias in the regression analyses.

Conclusion: This study has documented substantial use of various restrictions on access to newer branded antidepressants in U.S. commercial health plans. Most of these medications had generic equivalents that offered at least some substitutability, reducing access concerns. At the same time, it is worth noting that high copayments and administrative requirements can nonetheless be burdensome for some patients.

Implications for Health Policy: Health plans' pharmacy management approaches may concern policymakers less than in the early 2000s, due to the lesser distinctiveness of today's branded medications. This may change depending on future drug introductions.

Implications for Further Research: Future research should examine the impact of plans' pharmacy management approaches, using patient-level data.

Received 4 August 2015; accepted 8 October 2015