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ASAM counters insurance restrictions on access to opioid treatment drugs

June 26, 2013
by Gary A. Enos, Editor
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Having documented widespread restrictions on access to opioid addiction medications in both the public and commercial insurance markets, the American Society of Addiction Medicine (ASAM) is seeking to respond to these threats on the clinical and advocacy fronts.

In an interview with Addiction Professional following a daylong event attended by policy leaders in Washington, D.C., ASAM president Stuart Gitlow, MD, MPH, said the society will launch a process for establishing official clinical guidelines for opioid addiction treatment. At the same time, it will attempt to leverage the involvement of its addiction medicine specialists by building a coalition with other groups around improving access to care for opioid addicts.

With opioid use still rising, insurers becoming more restrictive in some areas, and another potential epidemic in marijuana use possibly around the corner, “We can’t move fast enough,” says Gitlow.

As part of the June 20 event that featured participation from numerous federal agencies, including the National Institute on Drug Abuse (NIDA) and the Food and Drug Administration (FDA), ASAM released a comprehensive report titled Advancing Access to Addiction Medications. The report featured surveys conducted in the Medicaid and private insurance markets from The Avisa Group and the Treatment Research Institute (TRI), respectively, in order to determine the degree to which state Medicaid offices and private insurers are offering unfettered access to methadone, buprenorphine and injectable naltrexone.

In both domains, similar types of restrictions have become commonplace across the country. The Medicaid analysis within the report found that while 28 states appear to cover all three federally approved medications for the treatment of opioid dependence in their Medicaid programs, prior authorization and other benefit approval mechanisms often serve to limit access. The report states that this can prove especially harmful within a patient population for whom immediate access might determine whether the patient decides to pursue treatment at all.

The Medicaid analysis pointed out, as one example of limited access, the case of a Southern state where only one methadone clinic is eligible to receive Medicaid reimbursement.

The analysis of the commercial insurance market focused on the 10 most populous states, examining two commercial plans and the largest small-group plan in each state. This study found that inclusion of a medication in a plan’s formulary does not always equate to open access, as prior authorization requirements and medication quantity and dosage limits are frequently applied.

Suboxone (the buprenorphine-naloxone combination) is the most widely available of the medications in the commercial market, with only a small number of plans covering Vivitrol (the injectable formulation of naltrexone), the report states. It adds that no commercial plan appears to provide coverage for methadone in opiate treatment programs.

In addition, according to the report, health plans often do not require counseling as part of opioid addiction treatment, despite the clear research evidence supporting the provision of medication and counseling in combination.

“There’s almost no place where a patient can be prescribed a medication for an opiate disorder without jumping through numerous hurdles,” says Gitlow. This occurs despite clear indications that using medication in conjunction with therapy improves outcomes and ultimately saves money, he says.

Appearing along with policy leaders at this month’s Washington, D.C. event was a buprenorphine patient (the Subutex formulation) who is now six months pregnant and doing well in her recovery, but who has faced barriers to staying on the medication. “By her third month of treatment, her insurance company was making the prior authorization requirement so great that she was having to consider paying for the medication out of pocket,” says Gitlow.

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