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The American Journal of Managed Care April 2018
Delivering on the Value Proposition of Precision Medicine: The View From Healthcare Payers
Jane Null Kogan, PhD; Philip Empey, PharmD, PhD; Justin Kanter, MA; Donna J. Keyser, PhD, MBA; and William H. Shrank, MD, MSHS
Care Coordination for Children With Special Needs in Medicaid: Lessons From Medicare
Kate A. Stewart, PhD, MS; Katharine W.V. Bradley, PhD, MBA; Joseph S. Zickafoose, MD, MS; Rachel Hildrich, BS; Henry T. Ireys, PhD; and Randall S. Brown, PhD
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Cost Sharing and Branded Antidepressant Initiation Among Patients Treated With Generics
Jason D. Buxbaum, MHSA; Michael E. Chernew, PhD; Machaon Bonafede, PhD; Anna Vlahiotis, MA; Deborah Walter, MPA; Lisa Mucha, PhD; and A. Mark Fendrick, MD
A Payer–Provider Partnership for Integrated Care of Patients Receiving Dialysis
Justin Kindy, FSA, MAAA; David Roer, MD; Robert Wanovich, PharmD; and Stephen McMurray, MD
Financial Burden of Healthcare Utilization in Consumer-Directed Health Plans
Xinke Zhang, PhD; Erin Trish, PhD; and Neeraj Sood, PhD
Progress of Diabetes Severity Associated With Severe Hypoglycemia in Taiwan
Edy Kornelius, MD; Yi-Sun Yang, MD; Shih-Chang Lo, MD; Chiung-Huei Peng, DDS, PhD; Yung-Rung Lai, PharmD; Jeng-Yuan Chiou, PhD; and Chien-Ning Huang, MD, PhD
Physician and Patient Tools to Improve Chronic Kidney Disease Care
Thomas D. Sequist, MD, MPH; Alison M. Holliday, MPH; E. John Orav, PhD; David W. Bates, MD, MSc; and Bradley M. Denker, MD
Limited Distribution Networks Stifle Competition in the Generic and Biosimilar Drug Industries
Laura Karas, MD, MPH; Kenneth M. Shermock, PharmD, PhD; Celia Proctor, PharmD, MBA; Mariana Socal, MD, PhD; and Gerard F. Anderson, PhD
Provider and Patient Burdens of Obtaining Oral Anticancer Medications
Daniel M. Geynisman, MD; Caitlin R. Meeker, MPH; Jamie L. Doyle, MPH; Elizabeth A. Handorf, PhD; Marijo Bilusic, MD, PhD; Elizabeth R. Plimack, MD, MS; and Yu-Ning Wong, MD, MSCE

Cost Sharing and Branded Antidepressant Initiation Among Patients Treated With Generics

Jason D. Buxbaum, MHSA; Michael E. Chernew, PhD; Machaon Bonafede, PhD; Anna Vlahiotis, MA; Deborah Walter, MPA; Lisa Mucha, PhD; and A. Mark Fendrick, MD
Higher cost sharing is associated with reduced branded antidepressant initiation among patients trying generic therapy. Dynamic benefit designs could enhance access to branded medications when appropriate.

Objectives: To determine the relationship between consumer cost sharing for branded antidepressants and the initiation of branded therapy among patients with major depressive disorder (MDD) filling a prescription for generic MDD medication. 

Study Design: Retrospective cross-sectional analyses.

Methods: Patients aged 18 to 64 years with MDD who filled a generic antidepressant were identified in commercial claims data for 2012 to 2014. For each year-specific analysis, an average cost-sharing index for branded antidepressants at the level of the plan was computed. Multivariable models were used to estimate the relationship between plan-level cost sharing for branded antidepressant medications and the filling of branded prescriptions, with demographic and clinical variables as covariates. 

Results: For patients with MDD filling a generic prescription, increases in branded cost sharing were associated with significant decreases in the likelihood of filling a branded antidepressant in each year (<.001). Results in 2012 imply that a shift from the 0th to 90th percentile in the branded cost-sharing index corresponded with a 9.5% decrease in the relative likelihood of a branded fill among patients receiving a generic antidepressant. The corresponding figures for 2013 and 2014 were 9.3% and 3.5%, respectively. 

Conclusions: In MDD, patients and clinicians who dutifully adhere to guidelines requiring a trial of first-line medication may ultimately require therapy with alternate agents to achieve adequate disease control. A “reward the good soldier” benefit design would lower cost sharing for higher-tier evidence-based therapies when clinically indicated. Results suggest that narrowing the gap in cost sharing between branded and generic medications following a trial of a generic agent might improve access to second-line treatment in MDD.

Am J Manag Care. 2018;24(4):180-186
Takeaway Points

Cost sharing for any particular medication is generally fixed and rarely reflects patient-specific factors that might change over the course of a disease. These factors may have important implications for appropriateness. 
  • Higher cost sharing for branded antidepressants is associated with reduced likelihood of initiation of branded therapy among patients receiving a generic medication. 
  • The literature suggests that a branded option may be the best choice for a patient following suboptimal response to a first-line medication.
  • Future work should test the merit of “reward the good soldier” benefit designs that reduce cost sharing for more expensive medications following treatment failure with generics.
Payers and purchasers increasingly rely on high cost sharing to reduce expenditures. The use of high-deductible health plans (HDHPs), in particular, is growing rapidly.1-3 In 2016, 39% of Americans younger than 65 years with private insurance were enrolled in an HDHP3; that same year, 57% of firms with 1000 or more workers offered an HDHP plan option.2 Apart from deductibles, high cost sharing for covered prescription medications may bring about cost-related nonadherence.4-8 Average co-payments in 2016 for third- and fourth-tier medications were $57 and $102, respectively, for employer-sponsored coverage,2 while beneficiaries in the most popular Medicare Part D prescription drug plans faced coinsurance of 30% to 50% for nonpreferred branded medications.9 Advocates and researchers have raised concerns that cost sharing at these levels may reduce receipt of needed high-value services, especially among poorer enrollees and those with chronic medical conditions.10,11

In addition to high consumer cost sharing, payers and pharmacy benefit managers employ utilization management techniques, such as step therapy and prior authorization, to limit spending. A 2016 Pharmacy Benefit Management Institute report found that 83% of employers surveyed applied step therapy requirements and another 9% were considering their use.12 More than one-third of employer plans used prior authorization and/or step therapy requirements for branded mental health medications in 2016, as did 60% of exchange-sold plans.13

These policies have serious consequences for patients and society, including for those living with major depressive disorder (MDD). MDD is the second leading medical cause of long-term disability and the fourth leading cause of global burden of disease; it is predicted to become the second highest cause of disability by 2020.14,15 MDD affects more than 15 million Americans, accounting for more than $95 billion in direct costs and $105 billion in lost workplace productivity each year.16 New approaches to reduce the burden of this illness merit consideration.

The natural history of chronic conditions often necessitates multiple therapies to achieve desired clinical outcomes. In MDD, more than two-thirds of patients fail to achieve remission with first-line treatment.17 For many of these patients, more effective treatment options may be available, but only at higher drug tiers that require greater cost sharing. Given the heterogeneity of patients with MDD and that several patient factors impact therapeutic response, successful treatment requires a personalized approach. Research has shown, for example, that a patient’s failure to respond to one selective serotonin reuptake inhibitor (SSRI) does not mean that he or she will not respond to another SSRI or to a serotonin–norepinephrine reuptake inhibitor (SNRI).18,19 Guidelines therefore generally recommend consideration of another SSRI or SNRI after unsuccessful trial of a first-line SSRI/SNRI.19,20

It is well established in the literature that greater out-of-pocket (OOP) costs for indicated chronic disease medications can reduce initiation and adherence, lower the likelihood of achieving desired health outcomes, and, for some conditions, increase acute care utilization.4-8,21-26 Under today’s more traditional formulary arrangements, patients with MDD who have a suboptimal response to a first-tier, usually generic, drug are often subject to higher cost sharing for access to therapies that may be more effective, by virtue of these therapies’ placement on higher tiers. A “reward the good soldier” approach, or “step edit with co-pay relief,” has received attention as an alternative strategy.27-30 This “dynamic” model would lower consumer cost sharing (ie, co-payment or coinsurance) for higher-tier evidence-based therapies, but only when first-line lower-cost therapies prove ineffective in achieving desired clinical outcomes. This would mean, for instance, that a patient with MDD who has not achieved adequate disease control after having tried a generic antidepressant would be subject to low cost sharing if prescribed a branded antidepressant. This would ensure that individuals with chronic disease, such as MDD, would not be penalized in the form of higher cost sharing simply because of their biology.


Given that consumer cost-sharing levels for specific medications are fixed and do not reflect the varying nature of most chronic diseases, rigorous analyses are warranted to explore the extent to which current formulary designs facilitate access to alternate options when first-line therapies prove ineffective. Accordingly, the objective of this study is to determine whether higher consumer cost sharing for branded MDD medications is associated with reduced initiation of second-line therapies for individuals diagnosed with MDD filling a prescription for a generic MDD medication. The findings have implications for the merit of piloting new benefit designs.



We used the Truven Health Analytics MarketScan Commercial Claims and Encounters Database from 2012 to 2014, the most recent complete calendar years available at the time the analyses were commenced. The database contains the inpatient medical, outpatient medical, and outpatient prescription drug experiences of approximately 200 million employees and their dependents covered under a variety of fee-for-service and managed care health plans between 1995 and 2014, including approximately 30 million covered lives in 2014.

Patient Cohort

Patients were included in each year-specific analysis if they had at least 1 claim with a diagnosis of MDD and 1 claim for a generic antidepressant during the 12-month year or the 3 months preceding the calendar year of interest. The lists of generic and branded medications used to treat MDD were obtained from First Databank. International Classification of Diseases, Ninth Edition, Clinical Modification codes were used to identify patients with MDD. Patients with less than 12 months of continuous medical and prescription coverage in any given year, younger than 18 years, older than 65 years, and/or having any claims indicative of pregnancy were excluded. Also excluded were patients in firm/plan combinations with fewer than 30 prescriptions for generic or branded antidepressant medication to ensure that the firm/plan-specific cost-sharing estimation was not unduly influenced by a relatively small number of prescriptions.


Use of branded antidepressant medications. The measure of antidepressant utilization was a binary variable, set equal to 1 if a patient filled at least 1 branded antidepressant prescription in the 12 months of the observation year. The variable was otherwise set to 0.

Cost sharing for branded antidepressant medications. For each year-specific analysis, an average co-payment/coinsurance at the level of the firm/plan was computed for 30-day adjusted branded antidepressant prescriptions based on the aggregated experience of attributed patients that year. Firm/plan-level values were assigned to each attributed patient. The use of firm/plan-specific experience rather than patient-level experience can help reduce endogeneity associated with the drug-related decision making of employees and allows for estimation of how much a branded antidepressant would have cost for patients who did not receive a branded drug in a given year. The measure of cost sharing was ranked across firm/plan combinations to calculate an index of branded antidepressant cost sharing.

Demographic and clinical variablesThe analyses included the following covariates: age, sex, geographic region, urban/rural residence, insurance plan type, patient relationship to the primary subscriber, and median household income in the zip code of residence. Age was also categorized into intervals of 18 to 34, 35 to 44, 45 to 54, and 55 to 64 years. For each patient, a Charlson Comorbidity Index score31 and the number of psychiatric diagnostic groupings were characterized.32 All covariates were measured as of January 1 of the calendar year of interest. 


Standard descriptive statistics were calculated for all demographic and clinical variables for each year-specific analysis. Descriptive statistics were also calculated to describe prescribing patterns, use, and cost sharing for branded antidepressant medications among included patients for each year. Cost-sharing indices for each year were calculated as described above. Multivariable models were used to assess the relationship between cost sharing and use of branded antidepressant medications at the patient level. The main covariate of interest was the co-payment/coinsurance index for branded medications. The models were adjusted for the demographic and clinical variables described in the previous paragraph.

Because the primary end point, any use of branded antidepressant medication, was binary, logistic regression models were used to estimate the probability of success (any use). The probability of branded use in varying cost-sharing percentile ranges was assessed using margins. Adjusted standard errors accounted for clustering.

Sensitivity analyses were conducted by varying the measure of total OOP responsibility (co-payment, coinsurance, and deduc­tible) for co-payment/coinsurance only in calculating the branded cost-sharing indices.

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