Removing Prior Authorization Can Increase Access to Opioid Use Treatments

Removing prior authorization requirements for buprenorphine for treatment for opioid use disorder can improve access to treatment in Medicaid enrollees, according to a new study published in the JAMA Health Forum.

This retrospective cross-sectional study analyzed changes in buprenorphine use from 2013 to 2020 in two state Medicaid programs — California and Illinois — before and after the removal of prior authorization requirements.

Shailina Keshwani

Investigators, led by Shailina Keshwani in the department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, analyzed these two states because they had removed buprenorphine prior authorization during the study period, and they had enough data points available to evaluate prescription changes before and after policy implementation.

California’s Medi-Cal program removed its requirement starting June 1, 2015, for either buprenorphine or buprenorphine-naloxone formulations when prescribed by qualified physicians for opioid use disorder treatment. Illinois eliminated prior authorization beginning, July 1, 2015.

Investigators noted that other states, such as Colorado, New Jersey, and Texas also implemented such policies; but there wasn’t sufficient data points to evaluate changes after the intervention using the quarter-level data, they said.

An estimated 1.4 million individuals in the Unites States had a diagnosis of opioid use disorder in 2019. Buprenorphine and buprenorphine-naloxone combination products are associated with decreased opioid-related overdoses and infectious disease transmission, investigators said. They noted that previous studies have reported that removal of prior authorization has been associated with improved health outcomes, with fewer emergency department visits and hospitalizations in Medicare enrollees.

Among the two state Medicaid programs (California and Illinois) that removed buprenorphine prior authorizations, there was a total of 702,643 and 415,115 eligible buprenorphine prescription claims, respectively.

In California, investigators saw an immediate increase in prescriptions for buprenorphine, but it was not statistically significant in the number (ie, level change) of all prescriptions. However, there was a statistically significant decreasing trend after the removal of prior authorization requirements. In Illinois, there was a statistically significant immediate increase in level and trend observed after the legislative changes in prior authorizations for medication-assisted treatments.

“In California, prescribing of buprenorphine for opioid use disorder was already increasing substantially before 2015; thus, the effect of removal of prior authorization for Medicaid enrollees was not as pronounced in the postimplementation period,” investigators wrote. “In addition, the prior authorization procedure in California may not be a substantial administrative barrier compared with that of Illinois. California uses a single, standardized form for all prior authorizations regardless of medication type, and prior authorization requests are accepted from any delivery means.”

Investigators noted that the database used, the Medicaid State Drug Utilization Data, lacks information about indications for corresponding prescriptions claims. Additionally, state Medicaid policies from rulemaking and administrative action may take longer to disseminate and they might be a delay in implementation.

“The findings from two state Medicaid programs may not be generalizable to other state Medicaid programs or other populations. Nevertheless, these findings can inform other state Medicaid programs and policy makers on the potential effects associated with the removal of prior authorization requirements for their patient population,” they wrote.