Fewer than half of Medicaid managed care plans provide all FDA-approved medications for alcohol use disorder

As health complications and deaths from alcohol use disorder (AUD) increase in the United States, it is critical that people who could benefit from medications have access to the drugs that the US Food and Drug Administration has approved to treat AUD. Yet, for individuals who have alcohol use disorder and are covered by Medicaid, accessing these medications is difficult; past research indicates that only about 1 in 20 Medicaid enrollees with alcohol use disorder receive these drugs.

Now, a new study led by Boston University School of Public Health (BUSPH) suggests that limited insurance coverage may be a possible barrier to these medications for individuals who have Medicaid managed care plans (MCP)—which is nearly 80% of all Medicaid enrollees.

Published in JAMA Network Open, the study found that less than half of Medicaid plans cover all four of the FDA-approved medications, which include acamprosate, disulfiram, and oral and injectable naltrexone. While 90% of Medicaid MCPs cover at least one of the AUD medications, only 43% cover all four options. The majority of these plans covered naltrexone—84% covered the oral version and 73% covered the injectable version—while 63% of MCPs covered disulfiram and 55% covered acamprosate.

“Medications for AUD can help people drink less, reduce cravings, and are associated with reduction in alcohol-related liver disease, but we see that over half of Medicaid managed care plans are not providing the full range of coverage for these potentially life-saving medications,” says study lead and corresponding author Dr. Maureen Stewart, research associate professor of health law, policy & management at BUSPH.

“People with alcohol use disorder need access to all four of the FDA-approved medications to accommodate variation in preferences due to potential side effects of the medications, and because different people may respond best to a specific medication.”

The team hopes that Medicaid managed care plans expand their list of covered medications to include all of the FDA-approved AUD medications. “State Medicaid programs contract with plans and can encourage plans to update their formularies,” Dr. Stewart says, adding that including all AUD medications on formularies would not only facilitate access for patients, but also reduce administrative burdens for providers. “Three of the four medications are available in generic form and therefore are not expensive, so costs should not be a burden.”

The study aimed to fill a knowledge gap on Medicaid MCP policies regarding AUD medications. Researchers from BUSPH, the Heller School for Social Policy and Management at Brandeis University, the University of South Carolina Arnold School of Public Health, and Booz Allen Hamilton, Inc. examined coverage and management of the four drugs, and explored any associations among insurance plan characteristics, medication coverage, and state policies.

The researchers analyzed publicly available insurance benefit documentation from 241 Medicaid-managed plans that offered coverage to adults ages 18–64 in 39 states and Washington, DC in 2021.

According to the findings, for-profit MCPs were substantially less likely to cover oral naltrexone, acamprosate, and disulfiram, and MCPs that managed behavioral health internally were less likely to cover all of the medications. The plans rarely applied prior authorization and drug quantity limits to these drugs—except for injectable naltrexone, for which 50% of MCPs required one or both of these requirements.

The team also found that plans that did not cover all four medications were partially concentrated in states with large populations of Black and Hispanic residents, as well as low-income residents, residents living in rural areas, and female residents. Alcohol-related morbidity and mortality rates disproportionately affect these groups, so ensuring access to all of the FDA-approved AUD medications could also help mitigate these racial, socioeconomic, and geographical disparities.

Nationwide, AUD affects more than 28 million American adults and contributes to increases in rates of cancer, heart disease, diabetes, and injuries. The team hopes the new data can inform national efforts to address substance use disorder through prevention and treatment, and ultimately lower AUD rates. But potential cuts to Medicaid funding under the Trump administration could hinder these goals.

“Medicaid managed care plans play a critical role in ensuring people have access to evidence-based alcohol treatment and behavioral health services,” Dr. Stewart says. “Proposed cuts to Medicaid would reduce access to alcohol and other substance use treatment for Medicaid enrollees.”

As health complications and deaths from alcohol use disorder (AUD) increase in the United States, it is critical that people who could benefit from medications have access to the drugs that the US Food and Drug Administration has approved to treat AUD. Yet, for individuals who have alcohol use disorder and are covered by Medicaid, accessing these medications is difficult; past research indicates that only about 1 in 20 Medicaid enrollees with alcohol use disorder receive these drugs.

Now, a new study led by Boston University School of Public Health (BUSPH) suggests that limited insurance coverage may be a possible barrier to these medications for individuals who have Medicaid managed care plans (MCP)—which is nearly 80% of all Medicaid enrollees.

Published in JAMA Network Open, the study found that less than half of Medicaid plans cover all four of the FDA-approved medications, which include acamprosate, disulfiram, and oral and injectable naltrexone. While 90% of Medicaid MCPs cover at least one of the AUD medications, only 43% cover all four options. The majority of these plans covered naltrexone—84% covered the oral version and 73% covered the injectable version—while 63% of MCPs covered disulfiram and 55% covered acamprosate.

“Medications for AUD can help people drink less, reduce cravings, and are associated with reduction in alcohol-related liver disease, but we see that over half of Medicaid managed care plans are not providing the full range of coverage for these potentially life-saving medications,” says study lead and corresponding author Dr. Maureen Stewart, research associate professor of health law, policy & management at BUSPH.

“People with alcohol use disorder need access to all four of the FDA-approved medications to accommodate variation in preferences due to potential side effects of the medications, and because different people may respond best to a specific medication.”

The team hopes that Medicaid managed care plans expand their list of covered medications to include all of the FDA-approved AUD medications. “State Medicaid programs contract with plans and can encourage plans to update their formularies,” Dr. Stewart says, adding that including all AUD medications on formularies would not only facilitate access for patients, but also reduce administrative burdens for providers. “Three of the four medications are available in generic form and therefore are not expensive, so costs should not be a burden.”

The study aimed to fill a knowledge gap on Medicaid MCP policies regarding AUD medications. Researchers from BUSPH, the Heller School for Social Policy and Management at Brandeis University, the University of South Carolina Arnold School of Public Health, and Booz Allen Hamilton, Inc. examined coverage and management of the four drugs, and explored any associations among insurance plan characteristics, medication coverage, and state policies.

The researchers analyzed publicly available insurance benefit documentation from 241 Medicaid-managed plans that offered coverage to adults ages 18–64 in 39 states and Washington, DC in 2021.

According to the findings, for-profit MCPs were substantially less likely to cover oral naltrexone, acamprosate, and disulfiram, and MCPs that managed behavioral health internally were less likely to cover all of the medications. The plans rarely applied prior authorization and drug quantity limits to these drugs—except for injectable naltrexone, for which 50% of MCPs required one or both of these requirements.

The team also found that plans that did not cover all four medications were partially concentrated in states with large populations of Black and Hispanic residents, as well as low-income residents, residents living in rural areas, and female residents. Alcohol-related morbidity and mortality rates disproportionately affect these groups, so ensuring access to all of the FDA-approved AUD medications could also help mitigate these racial, socioeconomic, and geographical disparities.

Nationwide, AUD affects more than 28 million American adults and contributes to increases in rates of cancer, heart disease, diabetes, and injuries. The team hopes the new data can inform national efforts to address substance use disorder through prevention and treatment, and ultimately lower AUD rates. But potential cuts to Medicaid funding under the Trump administration could hinder these goals.

“Medicaid managed care plans play a critical role in ensuring people have access to evidence-based alcohol treatment and behavioral health services,” Dr. Stewart says. “Proposed cuts to Medicaid would reduce access to alcohol and other substance use treatment for Medicaid enrollees.”