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Higher copayments of 3-tier drug formularies reduce the likelihood that individuals will use certain medications

Health care costs for medications to treat attention-deficit/hyperactivity disorder (ADHD) have jumped substantially. In response to these rising costs, many employers and health plans have adopted 3-tier drug formularies with progressively higher copayments for generic drugs, preferred brand-name drugs, and nonpreferred brand-name drugs. According to a recent study, the switch from 1-tier to a 3-tier system resulted in lower total ADHD medication spending relative to a comparison group. However, the switch also substantially increased out-of-pocket expenditures for families of children with ADHD and significantly decreased their probability of using these medications.

Although the shift did not cause most current users to substantially change their patterns of medication use relative to a comparison group, costs were shifted onto families. More studies should examine the impact of incentive formularies on the educational outcomes, self-esteem, and family and peer relationships of children with ADHD, suggests Haiden A. Huskamp, Ph.D., of Harvard Medical School. For instance, the generic drug methylphenidate lasts for 3 to 6 hours, which means that a child would have to take multiple doses during the school day. By contrast, the brand-name Concerta® (with the same active ingredient) lasts about 12 hours.

These differences influence medication compliance, the possibility of breakthrough symptoms, the potential for medication abuse, as well as stigma due to medication use or symptom breakthrough during school. Under the 3-tier formula studied, copayments were $8 for generic drugs, $30 for preferred brand-name drugs, and $60 for nonpreferred brand-name drugs. The prior 1-tier system required a $7 copayment for all 30-day prescriptions and $15 for all 90-day prescriptions filled through the mail-order program. This study was supported in part by the Agency for Healthcare Research and Quality (HS10803).

See "Impact of 3-tier formularies on drug treatment of attention-deficit/hyperactivity disorder in children," by Dr. Huskamp, Patricia A. Deverka, M.D., M.S., Arnold M. Epstein, M.D., M.A., and others, in the April 2005 Archives of General Psychiatry 62, pp. 435-441.

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