Currently Viewing:
The American Journal of Managed Care June 2016
Development of a Tethered Personal Health Record Framework for Early End-of-Life Discussions
Seuli Bose-Brill, MD; Matthew Kretovics, MPH; Taylor Ballenger, BS; Gabriella Modan, PhD; Albert Lai, PhD; Lindsay Belanger, MPH; Stephen Koesters, MD; Taylor Pressler-Vydra, MS; and Celia Wills, PhD, RN
The Value of Decreasing Health Cost Volatility
Marc Herant, PhD, MD, and Alex J. Brown, MEng, MBA
Variations in Patient Response to Tiered Physician Networks
Anna D. Sinaiko, PhD
Primary Care Appointment Availability and Nonphysician Providers One Year After Medicaid Expansion
Renuka Tipirneni, MD, MSc; Karin V. Rhodes, MD, MS; Rodney A. Hayward, MD; Richard L. Lichtenstein, PhD; HwaJung Choi, PhD; Elyse N. Reamer, BS; and Matthew M. Davis, MD, MAPP
Impact of Type 2 Diabetes Medication Cost Sharing on Patient Outcomes and Health Plan Costs
Julia Thornton Snider, PhD; Seth Seabury, PhD; Janice Lopez, PharmD, MPH; Scott McKenzie, MD; Yanyu Wu, PhD; and Dana P. Goldman, PhD
Risk Contracting and Operational Capabilities in Large Medical Groups During National Healthcare Reform
Robert. E. Mechanic, MBA, and Darren Zinner, PhD
The Evolving Role of Subspecialties in Population Health Management and New Healthcare Delivery Models
Dhruv Khullar, MD, MPP; Sandhya K. Rao, MD; Sreekanth K. Chaguturu, MD; and Rahul Rajkumar, MD, JD
When Doctors Go to Business School: Career Choices of Physician-MBAs
Damir Ljuboja, BS, BA; Brian W. Powers, AB; Benjamin Robbins, MD, MBA; Robert Huckman, PhD; Krishna Yeshwant, MD, MBA; and Sachin H. Jain, MD, MBA
Currently Reading
Review of Outcomes Associated With Restricted Access to Atypical Antipsychotics
Krithika Rajagopalan, PhD; Mariam Hassan, PhD; Kimberly Boswell, MD; Evelyn Sarnes, PharmD, MPH; Kellie Meyer, PharmD, MPH; and Fred Grossman, MD, PhD
Effects of Physician Payment Reform on Provision of Home Dialysis
Kevin F. Erickson, MD, MS; Wolfgang C. Winkelmayer, MD, ScD; Glenn M. Chertow, MD, MPH; and Jay Bhattacharya, MD, PhD
Adoption of New Agents and Changes in Treatment Patterns for Hepatitis C: 2010-2014
Xiaoxi Yao, PhD; Lindsey R. Sangaralingham, MPH; Joseph S. Ross, MD; Nilay D. Shah, PhD; and Jayant A. Talwalkar, MD

Review of Outcomes Associated With Restricted Access to Atypical Antipsychotics

Krithika Rajagopalan, PhD; Mariam Hassan, PhD; Kimberly Boswell, MD; Evelyn Sarnes, PharmD, MPH; Kellie Meyer, PharmD, MPH; and Fred Grossman, MD, PhD
This literature review evaluates the impact of restricted access to atypical antipsychotic drugs in individuals with schizophrenia or bipolar disorder.
This literature review is bound by the limitations of each respective study. Many of the studies are based on administrative and pharmacy claims data, which may be limited by potential inaccuracies and the inability to establish causality for treatment discontinuation. Also, estimates of drug expenditures likely did not account for manufacturer rebates offered to state Medicaid programs. Further, although we did seek to be more inclusionary given the limited evaluations in the literature, there was much heterogeneity among the studies reviewed (eg, study period, evaluation period, geographic area, inclusion of control, outcomes measured, and type of cost containment policy evaluated). Seven of the 15 studies evaluated did not include a control comparison from another state. In most studies, the follow-up period after policy implementation was relatively short (≤1 year). Although the studies represented multiple states and geographic regions, the policies may not be representative of all states and may not be generalizable. In addition to the policy restrictions imposed, outcomes can be affected by a number of other factors, including the underlying patient population (eg, disease state, gender, age, socioeconomic status), provider prescribing behavior, and patient response.

Formulary restrictions are often used as a cost-containment strategy in an environment of rising prescription drug costs. Although most studies that evaluated a pharmacy cost change demonstrated a reduction in costs, the overall cost change in most cases was not measured. A reduction in pharmacy costs after the implementation of formulary restriction policies is often accompanied by increases in healthcare utilization, such as hospitalizations and treatment discontinuation. There exists a gap in the literature as to whether restricted access to AAPs results in overall cost savings or, rather, shifts the cost burden from pharmacy spending to other parts of the healthcare system. Further investigation is warranted to fully understand the clinical and economic impacts of formulary restriction of AAPs for individuals with schizophrenia or bipolar disorder.

Author Affiliations: Sunovion Pharmaceuticals Inc (KR, MH, FG), Marlborough, MA; Xcenda (KB, ES, KM), Palm Harbor, FL.

Source of Funding: This manuscript was supported by Sunovion Pharmaceuticals Inc.

Author Disclosures: Drs Boswell, Meyer, and Sarnes are employees of Xcenda, which is a consulting company that provides services to several pharmaceutical companies, including Sunovian. Drs Rajagopalan and Grossman are employees, and at the time of this research Dr Hassan was an employee, of Sunovion Pharmaceuticals Inc.

Authorship Information: Concept and design (MH, KM); acquisition of data (KB, MH); analysis and interpretation of data (KB, MH); drafting of the manuscript (KB, FG, MH, KM, KR, ES); critical revision of the manuscript for important intellectual content (FG, MH, KM, KR, ES); obtaining funding (MH); and supervision (FG, MH, KR, ES).

Address correspondence to: Kimberly Boswell, MD, 4114 Woodlands Pkwy, Ste 500, Palm Harbor, FL 34685. E-mail:

1. Kessler RC, Chiu WT, Demler O, Merikangas KR, Walters EE. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):617-627.

2. Mark TL, Levit KR, Coffey RM, et al. National expenditures for mental health services and substance abuse treatment, 1993-2003 [SAMHSA pub No. SMA 07-4227]. Substance Abuse and Mental Health Services Administration website. Published 2007. Accessed April 10, 2013.

3. Crowley JS, Ashner D, Elam L. Medicaid outpatient prescription drug benefits: findings from a national survey, 2003. Kaiser Family Foundation website. Published December 2003. Accessed April 11, 2013. 

4. Cunningham PJ. Medicaid cost containment and access to prescription drugs. Health Aff (Millwood). 2005;24(3):780-789.

5. Lehman AF, Lieberman JA, Dixon LB, et al; American Psychiatric Association; Steering Committee on Practice Guidelines. Comment in. Practice guideline for the treatment of patients with schizophrenia, second edition. Am J Psychiatry. 2004;161(suppl 2):1-56. 

6. American Psychiatric Association. Practice guideline for the treatment of patients with bipolar disorder (revision). Am J Psychiatry. 2002;159(suppl 4):1-50.

7. Soumerai SB, McLaughlin TJ, Ross-Degnan D, Casteris CS, Bollini P. Effects of limiting Medicaid drug-reimbursement benefits on the use of psychotropic agents and acute mental health services by patients with schizophrenia. N Engl J Med. 1994;331(10):650-655. 

8. Farley JF, Cline RR, Schommer JC, Hadsall RS, Nyman JA. Retrospective assessment of Medicaid step-therapy prior authorization policy for atypical antipsychotic medications. Clin Ther. 2008;30(8):1524-1539; discussion 1506-1507. doi: 10.1016/j.clinthera.2008.08.009.

9. McCombs JS, Mulani P, Gibson PJ. Open access to innovative drugs: treatment substitutions or treatment expansion? Health Care Financ Rev. 2004;25(3):35-53.

10. Abouzaid S, Jutkowitz E, Foley KA, Pizzi LT, Kim E, Bates J. Economic impact of prior authorization policies for atypical antipsychotics in the treatment of schizophrenia. Popul Health Manag. 2010;13(5):247-254. doi: 10.1089/pop.2009.0063.

11. Law MR, Ross-Degnan D, Soumerai SB. Effect of prior authorization of second-generation antipsychotic agents on pharmacy utilization and reimbursements. Psychiatr Serv. 2008;59(5):540-546. doi: 10.1176/

12. Simeone JC, Marcoux RM, Quilliam BJ. Cost and utilization of behavioral health medications associated with rescission of an exemption for prior authorization for severe and persistent mental illness in the Vermont Medicaid program. J Manag Care Pharm. 2010;16(5):317-328.

13. Zhang Y, Adams AS, Ross-Degnan D, Zhang F, Soumerai SB. Effects of prior authorization on medication discontinuation among Medicaid beneficiaries with bipolar disorder. Psychiatr Serv. 2009;60(4):520-527. doi: 10.1176/

14. Soumerai SB, Zhang F, Ross-Degnan D, et al. Use of atypical antipsychotic drugs for schizophrenia in Maine Medicaid following a policy change. Health Aff (Millwood). 2008;27(3):w185-w195. doi: 10.1377/hlthaff.27.3.w185.

15. Lu CY, Adams AS, Ross-Degnan D, et al. Associations between prior authorization for psychiatric medications and use of health services among Medicaid patients with bipolar disorder. Psychiatr Serv. 2011;62(2):186-193. doi:  10.1176/

16. Vogt WB, Joyce G, Xia J, Dirani R, Wan G, Goldman DP. Medicaid cost control measures aimed at second-generation antipsychotics led to less use of all antipsychotics. Health Aff (Millwood). 2011;30(12):2346-2354. doi: 10.1377/hlthaff.2010.1296.

17. Lu CY, Soumerai SB, Ross-Degnan D, Zhang F, Adams AS. Unintended impacts of a Medicaid prior authorization policy on access to medications for bipolar illness. Med Care. 2010;48(1):4-9. doi: 10.1097/MLR.0b013e3181bd4c10.

18. Busch AB, Frank RG, Lehman AF. The effect of a managed behavioral health carve-out on quality of care for Medicaid patients diagnosed as having schizophrenia. Arch Gen Psychiatry. 2004;61:442-448.

19. Robst J. Changes in antipsychotic medication use after implementation of a Medicaid mental health carve-out in the US. Pharmacoeconomics. 2012;30(5):387-396. doi: 10.2165/11539830-000000000-00000.

20. Fung V, Price M, Busch AB, et al. Adverse clinical events among Medicare beneficiaries using antipsychotic drugs: linking health insurance benefits and clinical needs. Med Care. 2013;51(7):614-621.

21. Walthour A, Seymour L, Tackett R, Perri M. Assessment of changes in utilization of health-care services after implementation of a prior authorization policy for atypical antipsychotic agents. Ann Pharmacother. 2010;44:809-818. doi: 10.1345/aph.1M620.

22. MacKinnon NJ, Kumar R. Prior authorization programs: a critical review of the literature. J Managed Care Pharm. 2001;7(4):297-302.

23. Ascher-Svanum H, Faries DE, Zhu B, Ernst FR, Swartz MS, Swanson JW. Medication adherence and long-term functional outcomes in the treatment of schizophrenia in usual care. J Clin Psychiatry. 2006;67(3):453-460.

24. Lacro JP, Dunn LB, Dolder CR, Leckband SG, Jeste DV. Prevalence of and risk factors for mediation nonadherence in patients with schizophrenia: a comprehensive review of recent literature. J Clin Psychiatry. 2002;63(10):892-909.

25. Offord S, Lin J, Mirski D, Wong B. Impact of early nonadherence to oral antipsychotics on clinical and economic outcomes among patients with schizophrenia. Adv Ther. 2013;30(3):286-297. doi: 10.1007/s12325-013-0016-5.

26. Sun SX, Liu GG, Christensen DB, Fu AZ. Review and analysis of hospitalization costs associated with antipsychotic nonadherence in the treatment of schizophrenia in the United States. Curr Med Res Opin. 2007;23(10):2305-2312.

27. Brown CM, Nwokeji E, Rascati KL, Zachry W, Phillips GA. Development of the burden of prior authorization of psychotherapeutics (BoPAP) scale to assess the effects of prior authorization among Texas Medicaid providers. Adm Policy Ment Health. 2009;36:278-287. doi: 10.1007/s10488-009-0220-4

28. Soumerai SB. Benefits and risks of increasing restrictions on access to costly drugs in Medicaid. Health Aff (Millwood). 2004;23(1):135-146. 

29. Huskamp HA. Managing psychotropic drug costs: will formularies work? Health Aff (Millwood). 2003;22(5):84-96. 
Copyright AJMC 2006-2020 Clinical Care Targeted Communications Group, LLC. All Rights Reserved.
Welcome the the new and improved, the premier managed market network. Tell us about yourself so that we can serve you better.
Sign Up