Impact of Medicaid Prior Authorization Requirement for COX-2 Inhibitor Drugs in Nebraska

Objective. Determine the impact of a Prior Authorization Requirement (PAR) program on Medicaid pharmacy expenditures and utilization. Data Source. Prescription claims for Nebraska Medicaid recipients who received a cyclooxygenase‐2 (COX‐2) inhibitor, a nonselective nonsteroidal antiinflammatory (NSAID) drug, or other pain relievers between July 2001 and June 2003. Study Design and Data Collection/Extraction. This was a retrospective cross‐sectional study with a 12‐month pre‐PAR implementation period and a 12‐month post‐PAR implementation period. Pharmacy transactions for COX‐2 inhibitors, NSAIDs, other pain relievers, and gastroprotectants were identified by their National Drug Code (NDC) in a Microsoft SQL query. The PAR was designed to approve COX‐2 inhibitor use only for recipients at high risk of GI side effects while restricting access to those patients at low to moderate risk of GI side effects. Principal Findings. One year following implementation of the PAR, overall expenditures on COX‐2 inhibitors for Nebraska Medicaid dropped 50 percent. The overall impact on pharmacy expenditures, including NSAIDs, pain relief medications, and gastroprotectants when necessary to relieve gastrointestinal (GI) side effects, for those recipients who switched from a COX‐2 inhibitor to an NSAID or other pain relievers was a decline of approximately 35 percent. Conclusion and Implications for State Policy. PAR for COX‐2 inhibitors successfully reduced Medicaid prescription expenditures. Recipients at high risk for GI side effects appropriately received COX‐2 inhibitors. Recipients at low to moderate risk for GI side effects who were switched to NSAIDs or other pain relievers had lower overall prescription expenditures. Further research is needed to determine the impact of PAR on overall health outcomes and costs. In this study, rather than take a “one size fits all” approach to prescription drug cost‐saving strategies, Medicaid policy makers understood that patient variation required accurate identification of disease severity to determine when equally efficacious low‐cost alternatives were appropriate.