The Affordable Care Act has expanded access to insurance coverage to millions and has reformed health insurance requirements to assure more-comprehensive coverage of behavioral health and prescription drugs. Government reports estimate that more than 8 million people have enrolled in a health plan offered on the health insurance exchange, including 5.8 million estimated to have made their first payments. In addition, as many as 8 million people have gained coverage through the expansion of Medicaid in 26 states and the District of Columbia, creating a new, lucrative sales channel for the pharmaceutical industry.

These changes significantly increase the total demand for behavioral health therapies, including schizophrenia, major depression, and bipolar disorder. The broad availability of effective generic medications in these categories has prompted exchange-based plans to use narrower formularies, significant utilization controls, and high cost-sharing to maximize use of generics. The mainstay class of SSRI and SNRI antidepressants is fully genericized, and patent expirations in recent years have also opened up a variety of generic choices within the high-priced class of atypical antipsychotics. Nevertheless, some branded drugs have preserved substantial shares of prescribing in commercial plans. Therapies available for schizophrenia, major depression, and bipolar disorder include Bristol-Myers Squibb/Otsuka's Abilify (aripiprazole), AstraZeneca’s Seroquel (quetiapine), Eli Lilly’s Zyprexa (olanzapine), Dainippon Sumitomo Pharma/Sunovion Pharmaceuticals’ Latuda (lurasidone), Actavis’ (formerly Forest Laboratories) Viibryd (vilasodone), and Pfizer's Pristiq (desvenlafaxine). New and emerging therapies expected to launch will have to compete with generic therapies including a generic version of Abilify expected to become available in 2015.

Questions Answered in This Report:

  • Impact of ACA on physician practices. How will the demand for behavioral health therapies increase under the ACA? How will the millions of newly insured patients be distributed between PCPs and psychiatrists?

  • Reimbursement and prescribing of therapies treating schizophrenia, bipolar disorder, and major depression on exchange-based plans. How do exchange-based plans’ drug formularies differ from those of commercial plans and Medicaid plans? Will they be open or closed? How much more restrictive will they be? How different will utilization restrictions be in Medicaid and exchange-based plans compared with traditional commercial plans? How have/will physicians incorporate Abilify, Seroquel XR, Brintellix, Fanapt, Saphris, and Latuda into their behavioral health practices, despite the growing availability of generic alternatives in most drug classes? How can brands establish or maintain market share despite the cost-cutting imperatives of the Medicaid and exchange-based plans expanding under the ACA?

  • Role of emerging therapies in commercial plans and exchange-based plans. What metrics will commercial plans use to determine coverage for emerging behavioral health therapies such as Actavis/Gedeon Richter’s cariprazine? How will those standards change in the new plans created under the ACA? What patient shares will emerging therapies such as Roche/Chugai’s bitopertin capture among patients covered by commercial and exchange-based plans?

Scope:

In this report, we explore the current and projected use of key established behavioral health therapies and more recently launched brands in the expanding U.S. population of patients insured by Medicaid and commercial plans to be accessed through healthcare exchanges. In a survey of 72 psychiatrists, 72 PCPs, and 44 MCO pharmacy and medical directors, we also gauge the potential reception of emerging behavioral health drugs, including Actavis/Gedeon Richter’s cariprazine, in commercial, Medicaid, and exchange-based plans. By evaluating the attitudes and expectations of prescribers and payers, stakeholders can gain an understanding of the strategies needed to navigate an historic expansion of the U.S. healthcare market.  

Markets covered: United States.

Primary research: Online survey of 72 psychiatrists, 72 PCPs, and 44 MCO pharmacy and medical directors.

Epidemiology: The following populations with behavioral health disorders are represented: schizophrenia, major depression, and bipolar disorder.

Population segments: Where appropriate, our data and analyses are segmented by the following populations with behavioral health disorders: schizophrenia, major depression, and bipolar disorder.

Author(s): Paula Wade

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