Blog Post

Insurers’ Utilization Management Tools Vary Widely on Anti-Nausea Drugs for Cancer

Chart of the Day: LDI Researchers Report Major Coverage Differences Across ACA and Medicaid Plans, Affecting Access to Drugs That Treat Chemo-Related Nausea

December 18, 2025

By:

Joanna Kim, MPH

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Figure adapted from Kyle et al in JAMA Network Open

Up to 80% of cancer patients suffer from chemotherapy-induced nausea and vomiting – a distressing side effect for patients undergoing potentially life-saving treatment. Preventing and managing these effects is critical for these patients, and evidence suggests that antiemetics—drugs that stop or prevent nausea and/or vomiting—can improve quality of life and treatment tolerability.

Research shows that antiemetics are both overused and underused compared to clinical practice guidelines. Coverage policies can help or hinder access to antiemetics, and insurers increasingly use utilization management tools, such as prior authorization, quantity limits, and step therapy, to manage their use and contain costs.

A new study by LDI Senior Fellow Michael Anne Kyle and colleagues quantified utilization management (UM) requirements for antiemetics in Medicaid and Affordable Care Act (ACA) Marketplace plans and found extensive variation by drug, coverage type, and state. A total of 348,215 drug-plan antiemetic formulations were included, split almost evenly between ACA and Medicaid plans.

The chart above highlights differences in UM requirements by drug and coverage type. Across all coverage types, brand antiemetics were subject to UM by prior authorization more often than generics (ACA: 9.5% brand, 4.3% generic; Medicaid: 72.7% brand, 17.9% generic). While this variation was expected, the team was surprised to find UM restrictions even on cheaper generic formulations.

Between coverage types, the team also found that ACA plans required prior authorization for 4.5% of antiemetics, while Medicaid plans required prior authorization for 19.6% of antiemetics. Identifying differences in UM is important given patient “churn” between ACA Marketplace and Medicaid plans. The differences “may affect the continuity of care for patients,” said Kyle.

She and colleagues also mapped utilization management by state, geographically highlighting the stark inconsistencies and complexities patients face in securing coverage for antiemetics.

The team suggests that plans and policymakers take a standardized approach to UM requirements for antiemetics. “Using clinical guidelines to inform policymaking,” said Kyle, “may promote more consistent, patient-centered coverage policies.”

The study, “Prior Authorization, Quantity Limits, and Step Therapy for Patient-Administered Antiemetics” was published October 6, 2025 in JAMA Network Open. Authors include Kaitlyn Vu, Arjun Gupta, Fumiko Chino, Justin Barnes, Bridgette Thorn, and Michael Anne Kyle.