MHA examines health plan coverage of mental-health medications | Behavioral Healthcare Executive Skip to content Skip to navigation

MHA examines health plan coverage of mental-health medications

December 9, 2014
by Julie Miller, Editor in Chief
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In a detailed report, Mental Health America (MHA) presented an analysis of health plans and their coverage of drugs commonly prescribed for mental health conditions. Findings suggest that coverage of drugs varies significantly by state and access to newer, brand drugs is more limited overall than generics.

Under the Affordable Care Act, health plans are selling policies through online exchanges, and such policies must meet minimum standards, which include coverage for treatment of behavioral health conditions. The law does allow plans to apply utilization management techniques such as step therapy, quantity limits and preapproved coverage authorization for certain drugs or treatments.

MHA’s “Behavioral Prescription Drug and Service Coverage: A Snapshot of Exchange Plans” demonstrates the need for consumers to do their homework on their health plan choices before signing up and also the need for health plans to provide more information to shoppers on the insurance exchanges.

What MHA found

MHA studied 72 plans in nine states (Arizona, California, Colorado, Illinois, Maryland, Montana, New Jersey, New York and Texas) to assess their coverage for 25 drug products.

For example, MHA noted that brand drug Fetzima was only covered in 19% of all health plans studied. Meanwhile, generic antidepressants Celexa (citalopram), Paxil (paroxetine) and Lexapro (escitalopram) were covered in 100 percent of the “Silver” health plans (relatively more generous coverage) and 97 percent of the “Bronze” health plans (relatively less generous coverage).

Drug coverage by state varies widely, according to MHA. For example, California and Colorado plans have lower average coverage rates (both at 62 percent) of the 25 behavioral health drug therapies compared to the other seven states in the report.

Utilization management seems to be used with more frequency and for more drugs in Arizona, California, Illinois and Texas, whether considered by brand, by generic or overall. For example, Illinois had the best average coverage rate of products across plans at 95 percent but also had the highest use of utilization management at 64 percent.

The index in the MHA report also includes detailed information on deductibles and other out-of-pocket costs for patients.

The 25 products studied included:

  • Abilify*
  • Brintellix*
  • Celexa
  • Clozaril
  • Cymbalta
  • Depakote
  • Efexor
  • Fetzima*
  • Geodon
  • Invega*
  • Lamictal
  • Latuda*
  • Lexapro
  • Lithane
  • Paxil
  • Pristiq*
  • Prozac
  • Risperdal
  • Saphris*
  • Savella*
  • Seroquel
  • Tegetrol
  • Viibryd*
  • Zoloft
  • Zyprexa

* Branded Drug Product