Just 43% of Medicaid managed care plans cover all FDA-approved alcohol use disorder medications

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Fewer than half of Medicaid managed care plans (MCPs) cover all four U.S. Food and Drug Administration (FDA)-approved medications for alcohol use disorder (AUD), potentially limiting patient access to personalized, evidence-based treatment, according to a new study published in JAMA Network Open by researchers at Boston University School of Public Health (BUSPH).

The study, which examined publicly available 2021 insurance benefit documentation from 241 Medicaid MCPs across 39 states and Washington, D.C., found that while 90% of these plans covered at least one AUD medication, just 43% included all four approved options — acamprosate, disulfiram, oral naltrexone, and injectable naltrexone — on their formularies.

“Medications for AUD can help people drink less, reduce cravings, and are associated with [a] 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 Maureen Stewart, PhD, study lead, corresponding author, and research associate professor of health law, policy, and 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 study determined that oral naltrexone was the most frequently covered medication, included in 84% of Medicaid MCPs, while injectable naltrexone was covered by 73%. Disulfiram and acamprosate were included in 63% and 55% of plans, respectively. Prior authorization and quantity limits were rarely applied, except for injectable naltrexone, which faced such restrictions in 50% of plans.

The limited coverage of AUD medications may contribute to the underutilization of pharmacotherapy for the disorder. Past research has shown that only one in 20 Medicaid enrollees with AUD receives medication-assisted treatment.

The new study suggests that insurance barriers, including restricted formularies, may be a contributing factor.

Disparities in coverage and impact on vulnerable populations

The researchers found that for-profit MCPs were significantly less likely to cover certain AUD medications, including oral naltrexone, acamprosate, and disulfiram. Additionally, plans that managed behavioral health services internally were less likely to cover all four medications.

Coverage gaps were more pronounced in states with high proportions of Black and Hispanic residents, low-income individuals, rural populations, and female enrollees — groups that experience disproportionately high rates of alcohol-related morbidity and mortality. The study’s authors noted that improving access to all FDA-approved AUD medications could help mitigate these disparities.

Policy and cost considerations

Medicaid managed care plans operate under contracts with state Medicaid programs, which can influence formulary decisions. The study’s authors suggested that state Medicaid agencies could play a role in encouraging plans to include all FDA-approved AUD medications.

“Three of the four medications are available in generic form and therefore are not expensive, so costs should not be a problem,” Stewart says.

However, potential federal cuts to Medicaid under the Trump administration could further restrict access to AUD treatment. The researchers warned that reduced funding may lead to even more restrictive formularies and greater barriers to care.

Addressing the AUD crisis

With more than 28 million American adults affected by AUD, expanding access to medications is a critical component of national efforts to combat substance use disorders. Alcohol-related deaths increased by 70% between 2012 and 2022, with particularly sharp rises during the COVID-19 pandemic.

Researchers emphasize the need for policy changes to expand Medicaid enrollees’ access to the full range of FDA-approved AUD medications. The study’s authors urge state Medicaid programs and managed care organizations to reassess their formularies, ensuring broader coverage to improve patient outcomes and mitigate alcohol-related health burdens.

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