Prior Authorization, Quantity Limits, and Step Therapy for Patient-Administered Antiemetics

Area of Science:

• Oncology
• Health Policy
• Pharmacoeconomics

Background:

• Antiemetics are crucial for cancer patient quality of life and treatment adherence, supported by level 1 evidence.
• Utilization management (UM) strategies like prior authorization, step therapy, and quantity limits are employed by insurers to control costs and optimize drug use.

Purpose of the Study:

• To analyze and characterize UM policies for antiemetics within Patient Protection and Affordable Care Act (ACA) Marketplace and Medicaid insurance plans.
• To identify variations in UM across different plan types, drug formulations, and geographic regions.

Main Methods:

• A cross-sectional study analyzed a national sample of 2024 Medicaid and ACA drug formularies.
• Data were linked with FDA National Drug Codes to identify formulations of 13 common self-administered antiemetics.
• UM policies (prior authorization, quantity limits, step therapy) were assessed for their application to these antiemetics.

Main Results:

• UM affected 39.7% of antiemetics in ACA plans and 43.4% in Medicaid plans.
• ACA plans restricted a higher proportion of generic (40.5%) vs. brand-name (17.4%) antiemetics.
• Medicaid plans restricted a higher proportion of brand-name (82.5%) vs. generic (42.2%) antiemetics.
• Quantity limits were the most common UM tool, applied to over one-third of antiemetics in both plan types.
• Significant variation in UM policies was observed across states and plans.

Conclusions:

• Substantial variability exists in UM requirements for antiemetics across insurance types (ACA, Medicaid), states, and drug characteristics.
• These variations can create administrative burdens for patients navigating cancer treatment.
• Standardizing UM policies may improve patient access and reduce administrative hurdles.