title: Management of Newer Antidepressant Medications in U.S. Commercial Health Plans.
abstract: 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.
  
  
  OBJECTIVE
  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.
  
  
  CONCLUSIONS
  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.
  
  
  CONCLUSIONS
  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.
  
  
  CONCLUSIONS
  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.
  
  
  CONCLUSIONS
  Future research should examine the impact of plans' pharmacy management approaches, using patient-level data.
authors.affiliation: Heller School of Social Policy and Management, Brandeis University, Waltham, MA 02454, USA, hodgkin@brandeis.edu.
authors.forename: Dominic
authors.initials: D
authors.lastname: Hodgkin
authors.forename: Constance M
authors.initials: CM
authors.lastname: Horgan
authors.forename: Timothy B
authors.initials: TB
authors.lastname: Creedon
authors.forename: Elizabeth L
authors.initials: EL
authors.lastname: Merrick
authors.forename: Maureen T
authors.initials: MT
authors.lastname: Stewart
mesh_terms: D000928:Antidepressive Agents / Q000191:economics* / Q000627:therapeutic use*; D015283:Citalopram / Q000191:economics / Q000627:therapeutic use; D003363:Cost Control / Q000191:economics; D017047:Cost Sharing / Q000191:economics; D000069468:Desvenlafaxine Succinate / Q000191:economics / Q000627:therapeutic use; D016527:Drug Costs / Q000706:statistics & numerical data*; D004363:Drug Utilization; D000068736:Duloxetine Hydrochloride / Q000191:economics / Q000627:therapeutic use; D016666:Fluvoxamine / Q000191:economics / Q000627:therapeutic use; D059033:For-Profit Insurance Plans / Q000191:economics*; D019538:Health Care Surveys; D006297:Health Services Accessibility / Q000191:economics; D006801:Humans; D019458:Insurance Coverage / Q000191:economics; D007356:Insurance, Pharmaceutical Services / Q000191:economics*; D011243:Preferred Provider Organizations / Q000191:economics; D017149:Private Sector / Q000191:economics*; D012642:Selegiline / Q000191:economics / Q000627:therapeutic use; D014481:United States; D000069470:Venlafaxine Hydrochloride / Q000191:economics / Q000627:therapeutic use
chemical_list: D000928:Antidepressive Agents; D015283:Citalopram; D012642:Selegiline; D000069470:Venlafaxine Hydrochloride; D000068736:Duloxetine Hydrochloride; D016666:Fluvoxamine; D000069468:Desvenlafaxine Succinate