Letter to the Editor regarding: Medicaid prescription limits and their implications for naloxone accessibility (by Roberts et al., 2021)

(Roberts et al. (2021) identify and describe policies that limit the number of prescriptions a beneficiary may fill across state Medicaid programs. The authors find that Medicaid prescription fill limits are barriers to accessing medications and may limit access to life saving drugs such as naloxone. The research team used an internet search and telephonic survey to identify state Medicaid programs with prescription fill limits. These policies are used to reduce the costs of Medicaid pharmacy benefits by limiting the number of prescriptions beneficiaries can receive each month. The authors identify ten states with such limits: Alabama, Arkansas, Illinois, Kansas, Louisiana, Mississippi, Oklahoma, South Carolina, Tennessee, and Texas and note that recipients in these states represent over 12 million individuals, or about 20 % of US Medicaid beneficiaries. The authors’ main conclusion is that “monthly prescription fill limit policies threaten to restrict naloxone access for opioid overdose harm reduction in 20 % of the adult Medicaid population.” This conclusion is not supported by a careful review of the Medicaid policies in the ten identified states as specific policies within each state program allow exemptions and overrides to prescription limits that greatly reduce the number of beneficiaries impacted.

Prescription fill limits impose barriers on access to medications, but the specific details of how states manage limits greatly reduce the number of beneficiaries that encounter limits. For example, Louisiana’s Medicaid pharmacy provider portal notes that (Pharmacy Benefits Management Services Manual Revision-B, 2021) some federally mandated beneficiary groups are exempt from the limitations: persons under 21 years of age; persons who are residents of long-term care institutions, individuals with intellectual disabilities; and beneficiaries who are pregnant. Because prescription limits are only applicable to adult Medicaid beneficiaries, the number of beneficiaries listed in Table 1 is misleading in that it represents all enrollees and not adults which make up a much smaller number of beneficiaries. As an illustrative case, Texas is shown with 3.5 million enrollees, but 3.1 million of those beneficiaries are under 21, exempt from limits (Roberts et al., 2021). Some states also impose limits on beneficiaries in the fee-for-service population, but not on beneficiaries in managed care. Texas allows enrollees in Managed Care unlimited prescriptions (Texas Medicaid and CHIP in Perspective, 2021) and about 96 % of Texas Medicaid beneficiaries are enrolled in Managed Care (Medicaid Managed Care Enrollment and Program Characteristics, 2018). Most states also allow exemptions and overrides for medically necessary prescriptions, preferred drugs, and 90-day maintenance drugs (Prescription Limit: Alabama Medicaid, 2021). Several states now also include naloxone on the preferred drug list, exempting it from the limits. After considering these exclusions and exemptions, it is likely that few, if any, Medicaid beneficiaries would be limited from receiving naloxone when medically necessary. While state policy interventions such as pharmacist prescribing and coprescription mandates have had some impact on increasing access to naloxone, more subtle barriers such as healthcare provider stigma toward naloxone prescribing and patient reluctance to accept naloxone prescritpions shoud be addressed. And, in the future, researchers should remember that when it comes to evaluating the impact of state Medicaid coverage policies, the devil is in the details.

Role of funding source

Nothing declared.

Contributors

All authors contributed to the development of the writing of the letter. All authors reviewed and approved the final version of the letter.

Declaration of Competing Interest

The authors report no declarations of interest.

Appendix A. Details about each state

Alabama: adults are limited to five drugs per month, but exclusions are noted for children, nursing home patients, antipsychotic drugs, HIV drugs, seizure drugs, and drugs covered under a mandatory maintenance program for drugs with 90 days supply. Overrides may be granted for cases where the prescribing physician notes medical necessity.

Arkansas: Each Medicaid-eligible beneficiary age twenty-one years and older is limited to three Medicaid-paid prescriptions per calendar month. Exceptions include prescriptions for beneficiaries under age 21, family planning products, prescriptions for long-term care residents, prescriptions for opioid use disorder treatment, and prescriptions for tobacco cessation products. The program extends the prescription drug monthly benefit limit up to six prescriptions for medically necessary maintenance medications. And recipients in the Living Choices Assisted Living Program are eligible for up to nine medically necessary prescriptions per month.

Illinois: Adult Medicaid beneficiaries are limited to four prescriptions per month. The pharmacy benefit guide notes that the “purpose of the Four Prescription Policy is to have providers review the entire medication regimen for patients taking more than four qualifying medications, and where possible and clinically appropriate, to reduce duplication, unnecessary medications, or poly-pharmacy. There is NO LIMIT on how many medications a patient may receive if the medications are clinically appropriate.” Drugs excluded from the four prescription limit are oncolytic; antiretroviral agents; immunosuppressives; antipsychotics; and non-drug items such as blood glucose test strips and monitors.

Kansas: Adult Medicaid beneficiaries are limited to four prescriptions per month. Drugs on the preferred drug list and 90 day maintenance program are excluded from the limit. Overrides are available for medical necessity.

Louisiana: Adult Medicaid beneficiaries are limited to four prescriptions pre month. Limits do not apply to recipients under age 21, pregnant women, individuals with intellectual disabilities, or those in Long Term Care. Overrides may be granted for cases where the prescribing physician notes medical necessity.

Mississippi: Adult Medicaid beneficiaries are limited to five prescriptions per month, six prescriptions for those in Managed Care. Drugs on the preferred drug list always count as generic, 90 day maintenance program drugs only count in the month they are dispensed. Overrides may be granted for cases where the prescribing physician notes medical necessity. Naloxone is on the preferred list.

Oklahoma: Adult Medicaid beneficiaries are limited to six prescriptions per month. Prenatal vitamins, birth control, HIV, cancer, and smoking cessation products are excluded from the limit. Limit increases to 13 per month for those in the ADvantage waiver program. Overrides may be granted for cases where the prescribing physician notes medical necessity.

South Carolina: Adult Medicaid beneficiaries are limited to four prescriptions per month. Beneficiaries in waiver programs are limited to six prescriptions per month. Insulin syringes, Aerosolized pentamidine, Clozapine, Family planning, supplies, and devices are excluded. Override are available for essential drugs for acute sickle cell disease, behavioral health disorder, cancer, cardiac disease, diabetes, end state lung disease, end stage renal disease, HIV, hypertension, life threatening illness, organ transplant, terminal illness. Beneficiaries in Healthy Connections waiver excluded from limits.

Tennessee: Adult Medicaid beneficiaries are limited to five prescriptions per month. Exceptions are granted for any medication on the automatic exemption list (Narcan is on the list).

Texas: Adult Medicaid beneficiaries are limited to three prescriptions per month. Any member enrolled in a Managed care plan there are no prescription limits.

https://www.medicaid.gov/Medicaid/downloads/medicaid-mc-enrollment-report.pdf

https://hhs.texas.gov/about-hhs/records-statistics/data-statistics/healthcare-statistics