Formulary Restrictions Impact

Page Banner Icon

Restrictive formulary access policies, such as prior authorization and step therapy, have been used by decision makers to manage costs for many drug classes, including Atypical antipsychotics (AAPs). AAPs are a class of drugs used to treat severe mental illnesses, such as schizophrenia and bipolar disorder.

Restricting access to this class of treatment, however, is associated with negative clinical, economic, and societal outcomes.

Clinical Impact:

Patients with schizophrenia subject to formulary restrictions were more likely to be hospitalized with 23% higher inpatient costs. Similar effects were observed for patients with bipolar disorder.1

Arrow Up Icon23%

Economic Impact:

Taking into account all inpatient, medical, and pharmacy expenditures patients with schizophrenia, subjecting atypical antipsychotics to formulary restrictions result in 16% higher annual costs (over $2,700 per patient).1

Dollar Sign Icon16%

Societal Impact:

Patients who discontinued or temporarily stopped taking their medications because of prescription drug coverage, utilization management, or copayment issues also had 3.2 times greater odds of being homeless.2

Arrow Up Icon3.2X

Prior authorization requirements for atypical antipsychotics are associated with a 22% increase in the likelihood of imprisonment.3

Arrow Up Icon22%

Resources

  1. Seabury et al., “Formulary Restrictions on Atypical Antipsychotics: Impact on Costs for Patients with Schizophrenia and Bipolar Disorder in Medicaid,” American Journal of Managed Care. 20(2): e52-e60. 2014.
  2. Medicaid Prescription Drug Policies and Medication Access and Continuity: Findings From Ten States. Joyce C. West, Ph.D., M.P.P., Joshua E. Wilk, Ph.D., Donald S. Rae, M.A., Irvin S. Muszynski, J.D., Maritza Rubio Stipec, Sc.D., Carol L. Alter, M.D., Karen E. Sanders, M.S., Stephen Crystal, Ph.D., and Darrel A. Regier, M.D., M.P.H. Psychiatric Services 2009 60:5, 601-610.
  3. Medicaid Prior Authorization Policies and Imprisonment Among Patients With Schizophrenia, Dana Goldman, PhD, John Fastenau, MPH, RPh, Riad Dirani, PhD, Eric Helland, PhD, Geoff Joyce, PhD, Ryan Conrad, PhD, Darius Lakdawalla, PhD, The American Journal of Managed Care, July 2014, Volume 20, Issue 7.