Medicare patients who might benefit from long-acting injectable antipsychotic medications (LAIAPs) are not often subject to restrictions such as prior authorization or step therapy (which involves using less expensive medications first), according to a survey study appearing in Psychiatric Services.
These findings suggest that other factors are likely responsible for the low utilization of LAIAPs in clinical practice, despite their demonstrated effectiveness in numerous research studies. “This discrepancy may be due to a low awareness of LAIAPs among patients with psychotic illnesses and missed opportunities in clinical practice to discuss transition to an LAIAP with patients,” wrote Samuel Bunting, M.D., M.S., of the University of Chicago, and colleagues.
The researchers used publicly available databases of the Centers for Medicare and Medicaid Services to examine the frequency of prior authorization or step therapy restrictions during the third quarters of 2019 to 2023 in Medicare Advantage, dual Medicare-Medicaid eligibility plans, and Medicare Part D prescription drug plans. Results were weighted by the number of enrollees in those plans. A total of 2,494 Medicare plans were available in every year, representing 1,694 Medicare Advantage plans, 296 dual Medicare-Medicaid plans, and 504 Part D plans.
Nine LAIAPs were included in the analysis: two formulations of aripiprazole, fluphenazine, haloperidol, olanzapine, two formulations of paliperidone, and two formulations of risperidone.
Prior-authorization requirements for LAIAPs were generally low (between 1 and 11%) across the three plan groups and declined slightly between 2019 and 2023. The exception was olanzapine, which carries warnings due to a risk of post-injection sedation or delirium. In 2019, for example, 25% of enrollees in Medicare Advantage, 25.9% in dual plans, and 50.5% in Part D plans were subject to prior authorization for olanzapine.
Use of step therapy was similarly uncommon across the three plan groups, with rates generally at 1% or less by 2023. Step-therapy requirements were higher for olanzapine for Medicare Part D enrollees (2.6% in 2023 compared with 0.1% for other LAIAPs).
“Additional education of patients and clinicians is likely needed to address other barriers in order to improve use of these medications,” the researchers wrote. “More research is needed to determine specific barriers from the perspectives of both patients and psychiatric providers to ensure that LAIAPs reach appropriate patients.”
For related information, see the Psychiatric News article “Too Little, Too Late: LAIs Remain Underused.”
(Image: Getty Images/iStock/Aja Koska)
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