Prescribing Restrictions

Prescribing restrictions (PrRs) may be the most frequently used form of prescribing influence. In managed care networks, prescribing restrictions are administrative policies that restrict payment for unapproved drug products. In hospitals, physical access may be restricted directly if the hospital pharmacy does not provide "non-formulary" (i.e., locally unapproved) drug products or requires prior authorization. Common examples of PrRs are (a) formularies that list acceptable choices and exclude or limit access to other agents, (b) prior approval requirements for access, (c) specific limits on number of prescriptions or total prescription expenditure per person per month, and (d) specific limits on prescriber drug expenditures.

Prescribing restriction is qualitatively different than educational approaches to influencing prescribing, e.g., academic detailing. PrR rules usually exact some penalty from noncompliant prescribers, for example, the inconvenience of being interrupted by the pharmacist and perhaps either changing a prescription or making special application for an unapproved drug.

A range of inconvenience may exist in how long a patient or prescriber must wait for approval of a nonformulary drug application or prior authorization, or in the amount a patient must pay as copayment for unapproved drug products. Further, some enforcement can be coercive, for example, refusal to pay for an unapproved drug, threat of terminating a noncompliant prescriber's participation in a program, or a hospital pharmacy's refusal to provide a nonformulary drug.

This section will review published literature on prescribing restrictions, mainly in ambulatory care. Some issues in interpreting this literature include vague terminology, vague or conflicting objectives for prescribing restrictions, and invalid assumptions. The balance of evidence, however, seems clearly against the cost-effectiveness of PrRs in primary care, especially in managed care organizations.

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