Restrictions on Access to Medications Include

• Drug Formularies
• Prior Authorization Requirements
• Fail First Policies
• Generic Substitutions
• Pharmaceutical Benefits Managers                                                                               
• Therapeutic Class Substitutions
• Tiered Co-payments
• Dispensing or Prescription Limits
• Drug Utilization Review Boards
• Reference-Based Formularies

Supporters argue that, technically, consumers still have access and that costs are reduced, but…

Restrictions Limit Access
Many consumers are forced to use medications that do not match their treatment needs and many consumers suffer needlessly while waiting for authorization.

• Restricted medications are often not prescribed.  Due to extensive paperwork requirements for restricted medications, many prescribers often do not bother with the process at all, even when the medication may be more effective.
• Consumers often are required to “fail-first.”  In some cases, consumers must have multiple treatment failures on the preferred medication on the state’s formulary before gaining access to the appropriate treatment.
• Consumers wait unnecessarily.  The turn around of the prior authorization process is often extremely slow.
• Consumers may unknowingly receive a different medication or a generic substitute.  Even slight differences in the chemistry of a medication may harm the consumer.

• Restricting Access to Psychotropic Medications

And Restrictions Can Drive Up Costs
Studies have demonstrated that restrictive policies may achieve short term cost reductions, but at a major long-term cost to overall health expenditures:

• A study in the New England Journal of Medicine noted that limiting the use of psychotropic medications for those with schizophrenia increased costs 17-fold because of hospital costs incurred.[i]

• A study by Susan D. Horn, Ph.D., of the Institute for Clinical Outcomes Research and other researchers found that the more restrictive the formulary, the more patients used other, more expensive services.[ii]

• A Federally commissioned independent study found that although formularies do prevent access to excluded medications; any cost savings are eliminated by increases in spending in other, more expensive, service sectors.[iii]

• When California’s Medicaid program tried to contain costs through restrictive formularies, it found that the average prescription cost per patient increased from $245 to $726, and the average number of office visits increased from 3.2 to 6.6.[iv]

An Effective Medications Policy Will:

• Ensure that mental health consumers have access to the full range of medications as a part of their treatment plan.

• Entrust the provider and consumer to make decisions about which medications will be most effective.

• Explore the full range of community-based treatment options that will enable consumers to remain out of crisis and avoid expensive hospital care.

For additional information, please contact the Advocacy Resource Center at 1-800-969-NMHA (6642), Option 6 or shcrinfo@nmha.org

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