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. 2022 Nov 4;3(11):e224001.
doi: 10.1001/jamahealthforum.2022.4001.

Coverage and Prior Authorization Policies for Medications for Opioid Use Disorder in Medicaid Managed Care

Amanda J Abraham  1 , Christina M Andrews  2 , Samantha J Harris  3 , Melissa M Westlake  2 , Colleen M Grogan  4
Affiliations

Coverage and Prior Authorization Policies for Medications for Opioid Use Disorder in Medicaid Managed Care

Amanda J Abraham et al. JAMA Health Forum. .

Erratum in

  • Error in Figure Titles.
    [No authors listed] [No authors listed] JAMA Health Forum. 2022 Nov 4;3(11):e224653. doi: 10.1001/jamahealthforum.2022.4653. JAMA Health Forum. 2022. PMID: 36399354 Free PMC article. No abstract available.

Abstract

Importance: Medicaid is a key policy lever to improve opioid use disorder treatment, covering approximately 40% of Americans with opioid use disorder. Although approximately 70% of Medicaid beneficiaries are enrolled in comprehensive managed care organization (MCO) plans, little is known about coverage and prior authorization (PA) policies for medications for opioid use disorder (MOUD) in these plans.

Objective: To compare coverage and PA policies for buprenorphine, methadone, and injectable naltrexone across Medicaid MCO plans and fee-for-service (FFS) programs and across states.

Design, setting, and participants: This cross-sectional study analyzed MOUD data from 266 Medicaid MCO plans and FFS programs in 38 states and the District of Columbia in 2018.

Main outcomes and measures: For each medication, the percentages of MCO plans and FFS programs that covered the medication without PA, covered the medication with PA, and did not cover the medication were calculated, as were the percentages of MCO, FFS, and all (MCO and FFS) beneficiaries who were covered with no PA, covered with PA, and not covered. In addition, MCO plan coverage and PA policies were mapped by state. Analyses were conducted from January 1 through May 31, 2022.

Results: Coverage and PA policies were compared for MOUD in 266 MCO plans and 39 FFS programs, representing approximately 70 million Medicaid beneficiaries. Overall, FFS programs had more generous MOUD coverage than MCO plans. However, a higher percentage of FFS programs imposed PA for the 3 medications (47.0%) than did MCOs (35.9%). Furthermore, although most Medicaid beneficiaries were enrolled in a plan that covered MOUD, 53.2% of all MCO- and FFS-enrolled beneficiaries were subject to PA. Results also showed wide state variation in MCO plan coverage and PA policies for MOUD and the percentage of Medicaid beneficiaries subject to PA.

Conclusions and relevance: This cross-sectional study found variation in MOUD coverage and PA policies across Medicaid MCO plans and FFS programs and across states. Thus, Medicaid beneficiaries' access to MOUD may be heavily influenced by their state of residency and the Medicaid plan in which they are enrolled. Left unaddressed, PA policies are likely to remain a barrier to MOUD access in the nation's Medicaid programs.

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Conflict of interest statement

Conflict of Interest Disclosures: None reported.

Figures

Figure 1.
Figure 1.. Percentage of Medicaid Managed Care Organization (MCO) Plans vs Fee-for-Service (FFS) Programs and Percentage of MCO vs FFS Enrollees With Coverage for Medications for Opioid Use Disorder (MOUD) With and Without Prior Authorization, 2018
Figure 2.
Figure 2.. Percentage of Medicaid Managed Care Organization (MCO) Plans Covering Medications for Opioid Use Disorder by State, 2018
Figure 3.
Figure 3.. Percentage of All Medicaid Beneficiaries Enrolled in Managed Care Organization (MCO) Plans Covering Medications for Opioid Use Disorder by State, 2018
Figure 4.
Figure 4.. Percentage of Medicaid Managed Care Organization (MCO) Plans Requiring Prior Authorization by State, 2018
Figure 5.
Figure 5.. Percentage of All Medicaid Beneficiaries Enrolled in Managed Care Organization (MCO) Plans Subject to Prior Authorization by State, 2018
See this image and copyright information in PMC

References

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