Medicaid’s Most Costly Outpatient Drugs include Opioids, Opioid Agonists, and HCV and HIV Treatments

The Kaiser Commission on Medicaid and the Uninsured recently released an issue brief detailing the most costly outpatient drugs to Medicaid in 2014 and the first half of 2015. Using data from the Center for Medicare and Medicaid Services (CMS), the authors analyzed outpatient drug costs based on Medicaid spending (before rebates) to determine which drugs account for the greatest costs to Medicaid. In doing so, they found that the top 50 most costly outpatient drugs fall into one of three categories: a) frequently prescribed medications that are relatively inexpensive per prescription b) frequently prescribed medications that are also relatively expensive per prescription;  and c) medications that are prescribed less frequently but are relatively expensive.


The report shows that hydrocodone-acetaminophen, a low cost generic opioid pain reliever, is the most commonly prescribed drug from 2014-2015. Suboxone (buprenorphine/naloxone), an opioid agonist used to treat opioid use disorder, is also not among the most expensive drugs and is frequently prescribed to Medicaid patients despite prescribing limits that restrict who can prescribe this medication and how many patients can receive a prescription per prescriber. In the period covered by this study, buprenorphine/naloxone was limited to a maximum of 100 patients per authorized prescriber. A recent change by the Department of Health and Human Services has increased this limit to 275 patients.

Two HIV medications, Truvada (emtricitabine/tenofovir) and Atripla (efavirenz/emtricitabine/tenofovir), are in the second category, being both expensive and frequently prescribed. In contrast, two HCV medications are in the third category because they are expensive but not so frequently prescribed to Medicaid patients. These medications, Sovaldi (sofobuvir) and Harvoni (sofosbuvir/ledipasvir), are two of the top five most costly outpatient drugs per prescription for Medicaid. The lack of frequent prescriptions is not surprising because state Medicaid program limitations on HCV medication access due to budget constraints have been widely reported. The future may bring changes in access and cost, however. Some state Medicaid programs are eliminating HCV medication limitations as a result of legal challenges, and additional highly effective HCV medications have recently come to market, such as Zepatier (elbasvir/grazoprevir) and Epclusa (sofosbuvir/velpatasvir) at lower published prices. Thus Medicaid’s spending per prescription and the number of prescriptions for HCV medications may change in subsequent years.