Objective: Access to health care can be improved by controlling and optimizing expenditures, specifically the high-cost drugs such as atypical long-acting injectable (LAI) antipsychotics. This type of LAI is usually covered under the medical benefit and/or pharmacy benefit. We sought to compare financial outcomes of the medical benefit billing option with the pharmacy benefit billing option for atypical LAIs in an adult outpatient psychiatric clinic and to determine insurance companies' reasons for nonpayment when the medical benefit billing model was utilized.
Methods: A retrospective chart review with patients 18 years of age and older who were receiving atypical LAI antipsychotics in the outpatient psychiatric department during two time periods--January 7 through February 6, 2016 and August 15 through September 14, 2016--to evaluate medical (N = 31) and pharmacy (N = 23) benefit study periods, respectively.
Results: The estimated loss when using the medical benefit billing option was $14,520 per month. Switching to billing under the pharmacy benefit resulted in a monthly gain of $2,100. The net savings from the switch were estimated at $16,620 per month. No patient lost access to treatment or was switched to another medication solely because of the change in billing option. The reasons for nonpayment (N = 10) provided by medical insurance companies were prior authorization/step therapy required (40%), insurance terminated (30%), and coverage through Medicaid Rx only (30%).
Conclusion: This study revealed a significant financial loss related to atypical LAI antipsychotics when the medical benefit model was utilized. By switching to billing under the pharmacy benefit, potential savings for high-cost drugs such as LAIs can be realized.
Keywords: LAIs; billing; cost-saving; high cost; long-acting injectables; outpatient; reimbursement.