Antidepressant drug coverage may require special handling

Nov 16, 2015

A new Urban Institute study looks at the availability of antidepressants in marketplace insurance plans.

Marketplace plans usually cover a large number of antidepressants; however, consumers shopping for a plan may have a hard time finding out which antidepressant drugs are covered and how much they will have to pay out-of-pocket in order to get them if they enroll in a specific plan, according to a new Urban Institute study.

The research analyzed the marketplace and insurer websites of five select states to determine availability, accessibility, and cost of antidepressant prescription drugs. After analyzing three state-based marketplaces (California, Maryland, and Minnesota) and two states relying on HealthCare.gov (Alabama and Florida), the researchers found a significant level of variability in marketplace antidepressant coverage. 

Seventy four percent of insurers studied exclude anywhere from one to five antidepressants from their formularies (i.e., the list of drugs covered by a health plan); however, some insurers exclude as many as 15.

There’s also a lack of transparency when it came to consumers’ ability to find information about limits on coverage, out-of-pocket costs, and processes to appeal for exemptions for drugs not covered by a plan, according to the report.

Hempstead

“I think [the study] shows there is a lot of variation in the public exchanges now, which suggests that there is some uncertainty among payers about the best way to handle formulary treatment of this class of medications,” says Katherine Hempstead, director of the Robert Wood Johnson Foundation’s work on health insurance coverage.

“Payers and PBMs are scrutinizing formularies very closely and negotiating with manufacturers-what we observe in the marketplaces may not be that different from many employer-sponsored insurance plans,” Hempstead says.

The researchers recommended a series of improvements the marketplaces can make to improve consumers’ shopping experience, including requiring insurers to provide links to up-to-date, searchable lists of drugs they cover. Additionally, the researchers said marketplaces should build tools that would allow for consumers to search plans based on the coverage and cost of specific drugs. Furthermore, they said insurers could make out-of-pocket costs of drugs more transparent for consumers by instituting copayments for drugs rather than the strategy of coinsurance currently used by many insurers-for example, consumers paying a percentage of the total cost of a drug rather than a flat fee each time a prescription is filled.

“There are many medications in this category and for many patients there is a trial-and-error period where they may try a number of them to see what will be the most effective,” Hempstead says.

“Depression it is a very large category-especially among younger adults, but it is also important for seniors, and it is often comorbid with other chronic health conditions,” says Hempstead. “Successful treatment of depression can lead to improved outcomes on other conditions as well, so managed care executives want to make sure they are investing wisely and making sufficient therapies available to patients with this condition.”

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