Clearing Hurdles & Hitting Walls: Restrictions Undermine Part D Coverage of Mental Health Drugs

Despite instruction from the Centers for Medicare and Medicaid Services (CMS) to Medicare Part D plan providers to cover substantially all mental health drugs, many plans either have failed to provide coverage or have instituted utilization management techniques that restrict consumer access to antidepressant and antipsychotic medications. On average, nearly 23% of common antidepressant medications and nearly 24% of common antipsychotic medications were subject to utilization management or were absent from Part D plan formularies. Many plans apply utilization management differently depending on the source of the drug generic or sole-source brand name and commonly prescribed medications had higher rates of utilization management:

• 42% of antidepressants had access restrictions by First Health Premier plans; only one plan, SilverScript, imposed no access limitations
   
• 44% of antipsychotic medications had access restrictions by three plans: First Health Premier, Health Net Orange 003, and Health Net Orange 009 and all plans imposed some access limitations