Twenty-eight million adults in the U.S. have alcohol use disorder (AUD), and the life-threatening condition particularly impacts Medicaid populations.

Despite the existence of evidence-based medications for AUD, less than half of all Medicaid managed care plans cover all types of medications for AUD, according to a new study published in JAMA Network Open. 

“The results of this study emerge at a key moment in addressing escalating alcohol-related morbidity and mortality in the US,” researchers wrote. “Prior work has shown that initiating [medications for alcohol use disorder] (MAUD) before hospital discharge is associated with a substantial reduction in the risk of returning to the hospital or dying within 30 days. Widespread coverage of all MAUD could support these initiatives.”

Three-quarters of Medicaid enrollees are in Medicaid-managed care plans, which have “considerable discretion” to develop medication coverage policies, according to the report’s authors.

To determine the availability of AUD treatment medications, researchers analyzed publicly available insurance benefit documentation from 241 Medicaid managed care plans across 39 states and Washington. Researchers determined if plans covered four different medications for AUD: acamprosate, disulfiram, and injectable and oral naltrexone. They also analyzed if medications required prior authorizations or quantity limits.

While 90% of plans covered at least one medication for AUD, only 42% covered all four medications.

“Each MAUD has different considerations, including adverse effect profiles, route of administration, and dosing schedules, that must be evaluated by patients and their clinicians,” the study’s authors wrote. “Therefore, covering all MAUD may support enrollees seeking MAUD to choose the medication that works best for them.”

Naltrexone, both oral and injectable varieties, was the most commonly covered medication. The high coverage rate of injectable naltrexone, which is the most expensive medication, is likely due to the 2018 Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act, researchers wrote. The legislation requires plans to cover all FDA-approved medications for opioid use disorder, including injectable naltrexone.

Over 40% of plans employed prior authorizations and quantity limits for injectable naltrexone. These limitations may be attributed to the high cost of the medication.

Hispanic and Black people, as well as people with lower socioeconomic status, are disproportionately impacted by the consequences of excessive alcohol use disorder.

Matters are worsened by the lack of coverage for medications for AUD in states with high populations of these groups. Women are also at greater risk for alcohol-related health consequences compared to me and are overrepresented in Medicaid, yet managed care plans that did not cover all medications were in states with higher percentages of female Medicaid enrollees.

“Recent research points to disparities in AUD treatment utilization within Medicaid,” the study’s authors wrote. “Ensuring insurance coverage for all MAUD for these populations is essential to begin to address the increased need for AUD treatment among Black and Hispanic individuals, women, individuals with low socioeconomic status, and people residing in rural areas.”

More research is needed to determine why more plans do not cover all options for AUD. Researchers recommend that states and plans examine preferred drug lists (PDL) to ensure all medications for AUD are offered and limit utilization management practices.