Prior authorization, quantity limits, and step therapy for patient-administered antiemetics in 2024 Affordable Care Act Marketplace and Medicaid formularies.

116Background: Antiemetics have Level 1 evidence supporting their role in improving quality of life and treatment tolerability for patients with cancer; they are an essential part of supportive cancer care. Insurance companies apply utilization management tools — such as prior authorization (PA), step therapy (ST), and quantity limits (QL) — to control costs and guide prescribing practices. However, since many antiemetics are taken “as needed” for breakthrough nausea or vomiting, delays caused by these restrictions can jeopardize timely and effective symptom relief. We sought to characterize utilization management policies for antiemetics for Affordable Care Act (ACA) Marketplace and Medicaid plans. Methods: We linked 2024 ACA and Medicaid plan formulary data to the Food and Drug Administration’s National Drug Codes to identify formulations of the 13 most common self-administered (oral, sublingual, transdermal) antiemetics. We calculated the share of covered retail formulations subject to utilization management by coverage type (ACA, Medicaid, Medicaid managed care, and state-administered Medicaid), brand vs. generic, and by state. Results: Overall, utilization management affected 39.7% of covered antiemetics in ACA plans and 43.4% in Medicaid plans. In ACA plans, generic formulations faced more restrictions than brand-name drugs (40.5% vs 17.4%), while the reverse was true for Medicaid (82.5% brand vs 42.2% generic). Utilization management policies varied greatly by plan and state; some plans imposed restrictions on 100% of antiemetic formulations and others none. Quantity limits were the most prevalent tool, applied to over one-third of covered formulations in ACA (37.0%) and Medicaid plans (38.1%). For example, ondansetron was subject to quantity limits in 50.8% of ACA plans and 44.8% of Medicaid plans. Conclusions: There is substantial variation in utilization management requirements on antiemetics nationally across the ACA and Medicaid formularies. As restrictive policies could place effective management of cancer-related symptoms at risk, aligning policies with evidence-based clinical guidelines could help ensure that patients with cancer have timely access to symptom relief.