Large amounts of healthcare money is spent on medications, and these amounts are increasing. Spending more on medications could mean less money for hospitals, doctors and even other public services such as education or infrastructure. Misuse, overuse or underuse of medications may also result in poor health outcomes and a waste of money. Publically funded drug benefit plans look for ways to ensure better use of medications and to control costs without limiting health benefits. Policies that restrict reimbursement of specific prescription drugs -- often called 'prior' or 'special authorization' policies -- are one type of policy that may be used. Physicians generally apply on behalf of the patient and supply information verifying the patient's need before authorization is granted. These policies provide a safety valve when restrictions are applied by allowing for reimbursement when there is a need for the specific drug. If authorization is not obtained, an alternative and often cheaper drug with the same or similar benefit is reimbursed, or a patient may have the means to pay out-of-pocket expenses. Medications targeted for reduction in use are often newer, expensive drugs with cheaper, effective alternatives.
This review found 29 studies that evaluated policies that restrict reimbursement of specific prescriptions drugs. Where drugs have cheaper, effective alternatives and they target symptoms, this review found that reimbursement restriction polices can ensure better use of the medications with reduced costs and without an increase in the use of other health services, as would be expected if there were negative health effects of the restriction policies. Evaluation is required if alternative drugs are not effective substitutes. Removing restrictions for drugs that prevent complications of disease can result in an intended increase in their use as well as cost savings. When restrictions to reimbursement policies are designed using the best available evidence on the health impact of the medications, they support equitable access to the drugs that best support health by supporting the sustainability of publically subsidized drug plans.