The voices of Urban Institute's researchers and staff
November 13, 2015

Antidepressants and the ACA: Is your prescription covered and how hard is it to find out?

Antidepressants are the most commonly used prescription drugs for adults 18 to 44 and the third most commonly used prescription drugs overall. Approximately 11 percent of Americans over the age of 12 are taking antidepressants. The prevalence of depression and the frequent necessity of trying multiple medications prior to finding an effective treatment suggest the need for broad insurance coverage of antidepressants to ensure access to appropriate treatment regimens. But are the insurance plans offered under the Affordable Care Act (ACA) providing that coverage? We analyzed five states and found substantial differences in the breadth and transparency of coverage for antidepressants.

One objective of the ACA’s insurance marketplaces is to enhance competition among insurers by providing a transparent information source for consumers to identify the best insurance options for their needs. We analyzed the level of coverage and transparency of the coverage of antidepressants in marketplace and insurer web sites in five states: Alabama, California, Florida, Maryland, and Minnesota.

Within the five states and 35 insurers we studied, we found that insurers tend to cover a large percentage of antidepressants (38 unique active ingredients), but breadth of coverage does vary by state and insurer. While 26 of the insurers studied exclude just five or fewer antidepressants from coverage, some exclude as many as 12 to 15. Insurers do not seem to post formal exclusion policies or processes for appealing exclusions, potentially complicating consumers’ ability to judge a plan’s appropriateness for them.

All the marketplace and insurer websites we studied could be significantly more transparent about coverage. Marketplace browsing pages, where consumers can shop for plans, often do not provide direct links to the plan’s list of covered drugs. Even when they do, such as in the case of healthcare.gov, the links often do not take the consumer directly to the list but instead can leave them to hunt through many pages of an insurer’s website. Once found, these lists can sometimes be hard to search. Some list both brand and generic names and some list drugs by therapeutic category, but many have less flexibility. Some insurers display multiple drug lists without clarifying which one applies to marketplace plans.

It can also be difficult for consumers to determine how much they’ll have to pay for an antidepressant before enrolling in a plan. Plans charge different amounts for different tiers of drugs, depending on the cost to the insurer, and some web sites do not even show all the tiers (e.g., the insurer uses five different tiers but only displays four), or they use different names for the tiers when they describe cost-sharing requirements than they do next to specific drugs. Many use coinsurance (percentage of the insurer’s negotiated price) instead of co-payments (flat dollar amount per prescription), making it impossible for consumers to predict their out-of-pocket costs.

We also found that high insurance premiums are not necessarily an indicator of broader coverage or lower cost-sharing for antidepressants, as consumers might expect.

Based on our review of marketplace antidepressant coverage, we offer these recommendations:   

  1. Provide direct links from the marketplaces’ plan-browsing pages to searchable drug lists for each plan.
  2. Develop a more transparent and streamlined process for consumers to appeal the exclusion of a drug from insurance coverage and develop oversight functions to ensure fair and appropriate review of requests;.
  3. Convert coinsurance to co-pays so consumers can predict how much they’ll have to pay for a certain drug.
  4. Clearly label every drug with the cost-sharing tier, using the same tier names listed in the Summary of Benefits and Coverage (SBC).
  5. Include the complete list of cost-sharing tiers required by the plan on the browsing pages and SBCs.
  6. Limit use of prior authorization and step therapy for antidepressants and be more transparent in the nature of quantity limits;
  7. Provide tools that allow consumers to search available plans by coverage and cost-sharing for particular drugs.

In this June 14, 2011 photo, various prescription drugs on the automated pharmacy assembly line at Medco Health Solutions, are displayed in Willingboro, N.J. (AP Photo/Matt Rourke)

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