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State Medicaid programs vary in prior authorization policies for use of costly biologic antirheumatic drugs

Research Activities, May 2009, No. 345

Patients suffering from rheumatoid arthritis (RA) and other rheumatologic diseases are often treated with disease-modifying antirheumatic drugs (DMARDs) to reduce their symptoms of fatigue, joint pain, and stiffness and to slow disease progression. However, State Medicaid programs are struggling to manage the costs of the newer biologic DMARDs, such as adalimumab and etanercept. A 1-month supply of these drugs may cost 100 times more than a year's supply of an older synthetic DMARD such as methotrexate or hydroxychloroquine.

Many States have implemented prior authorization policies to limit use of biologic DMARDs. However, the policies vary, as do the clinical criteria patients must meet to be prescribed biologic DMARDs, according to a new study. There are currently no clinical guidelines for when such medications should be started. In this study, 32 States required prior authorization for one or more biologic DMARDs. States varied in the specific medications covered and the criteria required for a drug to be authorized, note Michael A. Fischer, M.D., M.S., and Harvard Medical School colleagues. For example, some States required documentation that the patient had a prior inadequate response to one or more synthetic DMARDs, while others required the prescription be written by a rheumatologist (the toxicity of these drugs often requires complex monitoring).

The researchers obtained prior authorization policy information on biologic DMARDs from State Medicaid programs and calculated the proportion of DMARD prescriptions and spending attributed to two of the biologic DMARDs, adalimumab and etanercept, in 1999 and 2005. Initially, fewer patients in prior authorization States used biologic DMARDs, but use increased over time to a level similar to that in States that did not require prior authorization for these drugs. Thus, the prior authorization policies seemed to have only a short-term effect on use of the targeted medications.

The study was supported in part by the Agency for Healthcare Research and Quality (HS17151).

More details are in "Prior authorization for biologic disease-modifying antirheumatic drugs: A description of US Medicaid programs," by Dr. Fischer, Jennifer M. Polinski, M.P.H., M.S., Amber D. Servi, A.B., and others, in the November 15, 2008, Arthritis & Rheumatism 59(11), pp. 1611-1617.

Current as of May 2009
Internet Citation: State Medicaid programs vary in prior authorization policies for use of costly biologic antirheumatic drugs: Research Activities, May 2009, No. 345. May 2009. Agency for Healthcare Research and Quality, Rockville, MD.