Branded Mental Health Meds Under the Exchanges

There may be lower use of branded prescriptions for schizophrenia, bipolar disorder, and depression on the health insurance exchange plans that are set to launch in January 2014, according to an analysis by Decision Resources. “For their patients on exchange-based plans, physicians would like to follow the same treatment pattern they have for their commercial patients. However, formulary design may constrain this behavior as managed care organizations push for generics. This tension will become more pronounced with the launch of newer premium-priced agents over the next few years that will be competing against entrenched therapies,” said Decision Resources senior director, Roy Moore.

More than a third of managed care organizations (MCOs) with a plan on the exchange expect to have a different formulary than the one used in their largest commercial product. The exchange formulary may feature fewer branded therapies, less preferred coverage of brands, and greater restrictions as MCOs seek to reduce costs by favoring generics.

Primary-care providers and psychiatrists expect a 19% to 34% increase in the number of patients they treat for schizophrenia, bipolar disorder, and depression since Medicaid eligibility will expand under the ACA.  Exchange-based plans will account for 17% of their patients in 12 months, highlighting the opportunity for the drug industry in exchanges. Expanded Medicaid eligibility will also present an opportunity for the drug industry, but more restrictive formularies in Medicaid will again favor generics. For more information, visit

Last Updated 10/20/2021

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