Year of Publication



Public Health

Date Available


Degree Name

Master of Public Health (M.P.H.)

Committee Chair

William Pfeifle, Ed.D.

Committee Member

Joseph Fink, B.S., Pharm., J.D.

Committee Member

Scott Hankins, Ph.D.


ABSTRACT Background: Second generation antihistamines (SGAs) are approved to treat seasonal and/or perennial allergic rhinitis (AR) and chronic idiopathic urticaria (CIU). It is estimated that 82% of Americans with AR use antihistamines, with the majority using SGAs due to their low side effect profile. As policy, over-the-counter (OTC) SGAs were not covered in this health plan population (cetirizine and loratadine products were available OTC prior to the study period, while fexofenadine products became available OTC during the study period). On January 1, 2012, the policy was extended to remove coverage of prescription-only SGAs (included desloratadine and levocetirizine products). Objectives: To assess the utilization of SGAs and SGA alternatives and to assess the rate of product switching associated with coverage changes. Methods: Pharmacy claim data from January 1, 2010 to October 31, 2012 were analyzed using the Truven Health Advantage Suite® system. Study participants had to be continuously enrolled, ≥18 years, and have received ≥1 prescription for a desloratadine, fexofenadine, or levocetirizine product during the study period. Three reference periods were evaluated to assess utilization patterns: (1) a period during which desloratadine, fexofenadine, and levocetirizine were covered; (2) a desloratadine and levocetirizine prescription-only coverage period during which fexofenadine OTC was introduced to the market; and (3) an SGA non-coverage period. Product switching was determined by having at least one new fill for a covered SGA or SGA alternative after a coverage change. Results: 84.6% of health plan participants taking SGAs did not switch to a prescription SGA alternative following SGA coverage discontinuation. For those who did switch, the most common therapeutic class switched to was intranasal corticosteroids (54%), which is the recommended first-line therapy for AR. More than half of the members who switched to a prescription SGA alternative were not persistent in filling the new medication, which could suggest that those members purchased an OTC SGA or left their condition untreated. Conclusion: The policy decision to discontinue coverage of SGAs was not associated with seeking a prescription alternative by the majority of plan members. With the potential for more medications to go OTC, this observational study illustrates that managed care organizations can efficiently manage drug costs for a fixed population by reserving scarce plan resources through appropriate benefit design management. Keywords: antihistamines, product switching, coverage, utilization, OTC medications What is already known about this subject  For the treatment of allergic rhinitis, prescription and over-the-counter (OTC) products exist as options for the 58 million Americans impacted by the upper respiratory condition, including second generation antihistamines (SGAs).  Intranasal corticosteroids have shown greater efficacy in trials, but SGAs continue to be the most heavily utilized therapeutic class.  The decision not to cover prescription products within a therapeutic class that has OTC products and the opportunity costs associated with such a decision are of interest to payers and employers within the health insurance industry. What this study adds  After drug coverage was removed for SGAs, increases in alternative prescription products were minimal, and the majority of health plan participants either purchased an OTC alternative or left the condition untreated.  The observed results from this study may be applicable to other health plans and can be used for the decision-making process for plan sponsors. Disclosure Statement No funding was received for this study. The authors report no conflict of interest regarding this study.

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