Coverage of Medications That Treat Opioid Use Disorder and Opioids for Pain Management in Marketplace Plans, 2017

Abstract

Many Marketplace plans either do not cover or require prior authorization for coverage of OUD medications, and these restrictions are often more common for OUD medications than for short-acting opioid pain medications. Regulators tasked with enforcement of the Mental Health Parity and Addiction Equity Act, which requires that standards for formulary design for mental health and substance use disorder drugs be comparable to those for other medications, should focus attention on formulary coverage of OUD medications.

Prescribing Practices of Nurse Practitioners and Physician Assistants Waivered to Prescribe Buprenorphine and the Barriers They Experience Prescribing Buprenorphine

“…In the past few years, insurance policies, including Medicaid, have changed to cover more medication‐based treatments and reduce restrictions on treatments . Still, 42% of our respondents identified insurance issues as a barrier, and 31% of providers identified financial or reimbursement concerns as a barrier.…”

“…Still, 42% of our respondents identified insurance issues as a barrier, and 31% of providers identified financial or reimbursement concerns as a barrier. The administrative task of filing for prior authorization could discourage providers from prescribing buprenorphine or taking on more patients . Limits on prescription duration or dosage can prevent patients from receiving adequate treatment .…”

“…26,36 In the past few years, insurance policies, including Medicaid, have changed to cover more medication-based treatments and reduce restrictions on treatments. [37][38][39] Still, 42% of our respondents identified insurance issues as a barrier, and 31% of providers identified financial or reimbursement concerns as a barrier. The administrative task of filing for prior authorization could discourage providers from prescribing buprenorphine or taking on more patients.…”

“…The administrative task of filing for prior authorization could discourage providers from prescribing buprenorphine or taking on more patients. 37,40,41 Limits on prescription duration or dosage can prevent patients from receiving adequate treatment. 40,42,43 Insurance policies must continue to evolve to facilitate patient access to MBT and limit provider barriers to accepting insurance coverage for MBT.…”

Addressing Obstacles to Evidence-Informed Pain Care

“…For some patients, buprenorphine is an effective option for pain that provides less risk for respiratory depression than full agonist opioids, 28 but insurance companies may not cover it or may approve it only if prescribed for treatment of opioid use disorder. 29 General association of these medications with opioid use disorder is most likely creating stigma-related barriers to their widespread use.…”