title: Medicaid prior-authorization programs and the use of cyclooxygenase-2 inhibitors.
abstract: BACKGROUND
  Over the past five years, selective cyclooxygenase-2 inhibitors (coxibs) have accounted for a growing proportion of prescriptions for nonsteroidal antiinflammatory drugs (NSAIDs). To control these expenses, many state Medicaid programs have implemented prior-authorization requirements before coxibs can be prescribed. We evaluated the effect of such programs on the use of coxibs by Medicaid beneficiaries.
  
  
  METHODS
  We surveyed state Medicaid agencies to determine whether prescription of coxibs required prior authorization and, if so, the criteria for authorization. For each program, we compared these criteria with evidence-based recommendations for prescribing of coxibs. Using data for all filled prescriptions in 50 state Medicaid programs from 1999 through the end of 2003, we calculated the proportion of defined daily doses of NSAIDs accounted for by coxibs. Time-series analyses were used to measure the changes in prescription patterns after the implementation of each prior-authorization program.
  
  
  RESULTS
  By 2001, coxibs accounted for half of all NSAID doses covered by Medicaid. This proportion varied widely according to the state in 2003, from a low of 11 percent to a high of 70 percent of all NSAID doses. Twenty-two states implemented prior-authorization programs for coxibs during the study period. Overall, the implementation of such programs reduced the proportion of NSAID doses made up by coxibs by 15.0 percent (95 percent confidence interval, 10.9 to 19.2 percent), corresponding to a decrease of 10.28 dollars (95 percent confidence interval, 7.56 dollars to 13.00 dollars) in spending per NSAID prescription. The effect of such programs was not influenced by the degree to which a prior-authorization program incorporated evidence-based prescribing recommendations.
  
  
  CONCLUSIONS
  The use of coxibs and spending on NSAIDs varies widely by state and declined substantially after the implementation of prior-authorization programs. Determining whether these reductions are clinically appropriate will have important implications for the development of rational drug-reimbursement policies.
authors.affiliation: Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02120, USA. mfischer@partners.org
authors.forename: Michael A
authors.initials: MA
authors.lastname: Fischer
authors.forename: Sebastian
authors.initials: S
authors.lastname: Schneeweiss
authors.forename: Jerry
authors.initials: J
authors.lastname: Avorn
authors.forename: Daniel H
authors.initials: DH
authors.lastname: Solomon
mesh_terms: D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000191:economics / Q000627:therapeutic use*; D016861:Cyclooxygenase Inhibitors / Q000191:economics / Q000627:therapeutic use*; D016527:Drug Costs; D011307:Drug Prescriptions / Q000592:standards* / Q000706:statistics & numerical data; D017723:Drug Utilization Review; D005569:Formularies as Topic / Q000592:standards; D006801:Humans; D007356:Insurance, Pharmaceutical Services / Q000191:economics / Q000592:standards* / Q000639:trends; D008484:Medicaid / Q000191:economics / Q000639:trends; D014481:United States
chemical_list: D000894:Anti-Inflammatory Agents, Non-Steroidal; D016861:Cyclooxygenase Inhibitors