Prior authorization policies for selective cyclooxygenase-2 inhibitors in Medicaid: a policy review.
BACKGROUND
Many state Medicaid programs use prior authorization programs to limit spending on cyclooxygenase-2 selective nonsteroidal anti-inflammatory drugs (coxibs). However, the evidence base for the prior authorization criteria has not been examined previously.


METHODS
We determined whether prior authorization was required for coxibs in state Medicaid programs and collected data on what precise criteria needed to be met for a coxib prescription to be authorized. Prior authorization criteria were compared to clinical evidence regarding which patients are most likely to benefit from coxibs.


RESULTS
By mid-2004, 35 states had implemented prior authorization requirements for coxibs. Of 5 major clinical factors that identify patients likely to benefit from coxibs, 18 states (51%) included all 5 factors and 9 states (26%) included 2 or fewer. Most states (33/35; 94%) required a previous trial of nonselective nonsteroidal anti-inflammatory drugs before a coxib would be authorized. Several prior authorization programs included factors that had no connection to the clinical evidence.


CONCLUSIONS
State Medicaid prior authorization policies for coxibs are heterogeneous in terms both of the criteria required to obtain a coxib and of the relationship of those criteria to clinical evidence. Development of clinically rational prescription drug policies should be a goal for all health insurers and represents an important priority for Medicare's prescription drug benefit program.
Fischer
Michael A
MA
Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, 1620 Tremont Street, Boston, MA 02120, USA. mfischer@partners.org
Cheng
Hailu
H
Schneeweiss
Sebastian
S
Avorn
Jerry
J
Solomon
Daniel H
DH
D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000008:administration & dosage; D003363:Cost Control; D052246:Cyclooxygenase 2 Inhibitors / Q000008:administration & dosage* / Q000009:adverse effects / Q000191:economics; D005938:Glucocorticoids / Q000008:administration & dosage; D006291:Health Policy / Q000191:economics*; D006801:Humans; D008484:Medicaid / Q000191:economics / Q000458:organization & administration*; D019338:Polypharmacy; D012051:Reimbursement Mechanisms / Q000191:economics / Q000458:organization & administration*; D012307:Risk Factors; D014481:United States; D014859:Warfarin / Q000008:administration & dosage
D000894:Anti-Inflammatory Agents, Non-Steroidal; D052246:Cyclooxygenase 2 Inhibitors; D005938:Glucocorticoids; D014859:Warfarin