Branded Behavioral Health Drugs May Be Constrained on Health Exchange-Based Plans

MCO's Support for Generics May Limit Prescribing of Branded Therapies for Schizophrenia, According to a New Report from Decision Resources

Sep 26, 2013, 09:00 ET from Decision Resources

BURLINGTON, Mass., Sept. 26, 2013 /PRNewswire/ -- Decision Resources, one of the world's leading research and advisory firms for pharmaceutical and healthcare issues, finds that branded therapies treating schizophrenia, bipolar disorder and depression may encounter reduced use on health insurance exchange plans that are set to launch in January 2014 as payers favor generics instead. More than a third of surveyed pharmacy directors at managed care organizations (MCOs) offering a plan on the health insurance exchange anticipate that plan will have a different formulary than the one used on their largest commercial product. This different formulary may feature fewer branded therapies, less preferred coverage of brands and greater restrictions as MCOs seek to reduce costs by favoring generics. If exchange-based plans are less generous than commercial products, surveyed psychiatrists and primary care physicians (PCPs) anticipate prescribing branded therapies to a smaller percentage of their patients on these plans.


The U.S. Physician and Payer Forum report entitled Healthcare Reform: Impact of Health Exchanges and Medicaid Expansion on Prescribing of Schizophrenia, Unipolar Depression, and Bipolar Disorder Drugs explores the impact of the Patient Protection and Affordable Care Act, under which Medicaid eligibility will expand (in states that approved the expansion) and individuals can purchase subsidized policies on health insurance exchanges. Because of these changes, surveyed PCPs and psychiatrists anticipate the number of patients they treat for schizophrenia, bipolar disorder and depression will increase by 34 percent and 19 percent, respectively. Moreover, exchange-based plans will account for 17 percent of their patients in 12 months' time, highlighting the opportunity that exists for the drug industry in exchanges. Expanded Medicaid eligibility will also present an opportunity for the drug industry, but more restrictive formularies in Medicaid will again favor generics.

"For their patients on exchange-based plans, physicians would like to follow the same treatment pattern they have for their commercial patients," said Decision Resources Senior Director Roy Moore. "However, formulary design may constrain this behavior as MCOs instead push for generics. This tension will become more pronounced with the launch of newer premium-priced agents over the next few years that will be competing against entrenched therapies."

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