Total cost of care for long-acting injectable antipsychotics for schizophrenia: Pharmacy vs medical benefit

BACKGROUND: Schizophrenia is a disabling mental illness affecting more than 2.8 million people in the United States. Long-acting injectable antipsychotics (LAIs) require less frequent dosing and may provide a more favorable treatment option over short-acting oral antipsychotics for patients with schizophrenia with suboptimal adherence or for those who desire a more convenient dosing regimen. There are 2 ways in which payers can cover LAIs: they can be covered under the medical benefit for administration by a health care provider or under the pharmacy benefit for self-administration by the patient. Existing literature is limited to general industry commentaries related to differences in health plan billing procedures under the pharmacy and medical benefit and the impact of these reimbursement pathways to health care institutions. However, the impact of various health plan coverage models on total cost of care (TCOC) and health care resource utilization (HCRU) among commercially insured patients receiving LAIs through pharmacy vs medical benefit is unknown. OBJECTIVE: To evaluate differences in TCOC and HCRU among commercially insured patients with schizophrenia who received LAIs through pharmacy vs medical benefit. METHODS: Retrospective study of Blue Cross Blue Shield of Michigan and Blue Care Network commercially insured members who received LAIs from January 1, 2021, to December 31, 2024. Two cohorts were included based on the benefit billed for LAI claim(s): (A) members with at least 1 LAI claim under pharmacy, or those with the first claim billed under medical with all subsequent claim(s) billed only under pharmacy, and (B) members with LAI claims billed only under medical. Members were continuously enrolled in both benefits and had an International Classification of Diseases, Tenth Revision code for schizophrenia on any claim during the pre-index period. Members were excluded if they switched post-index from the medical benefit to the pharmacy benefit cohort, or vice versa. RESULTS: After applying eligibility criteria and propensity score matching, there were 61 members in each cohort. Members in cohort B (medical benefit) had significantly higher mean direct-cause medical TCOC compared with cohort A (pharmacy benefit) (+$7,569; P < 0.023). However, after accounting for LAI spend for cohort B ($1,672) vs cohort A ($12,915), the total spend was not significantly different between the 2 groups (−$3,673; P < 0.34). Cohort B demonstrated significantly higher values in the following secondary endpoints: mean all-cause inpatient cost (+$12,633; P < 0.01), mean all-cause total medical cost (+$18,582; P < 0.02), and mean all-cause inpatient utilization (8.90 more claims per member; P < 0.006). However, similar results were observed for both groups across several key secondary endpoints, including mean all-cause pharmacy benefit costs (excluding LAI cost), mean emergency department costs and utilization, mean outpatient costs and utilization, and mean total utilization. CONCLUSIONS: Higher mean direct-cause medical TCOC spend was observed for cohort B, mainly driven by inpatient spend. However, similar outcomes were demonstrated across most other endpoints, which highlights the utility of cross-benefit LAI coverage.