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

Are patient-administered antiemetics subject to utilization management (prior authorization, quantity limits, step therapy) in Medicaid and Patient Protection and Affordable Care Act (ACA) plan formularies?In this cross-sectional study of 561 formularies and 348 215 unique drug-plan formulations, utilization management affected 39.7% of covered antiemetic medications in ACA plans and 43.4% in Medicaid plans, with wide variation by plan, drug, and geography.The findings of this study highlight extensive variation in patient exposure to utilization management by drug, plan, and state, underscoring the complexity patients face in attempting to secure financial coverage for supportive care medications.

Corresponding Author: Michael Anne Kyle, PhD, Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Dr, Philadelphia, PA 19104 (kylem@pennmedicine.upenn.edu).

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