RESEARCH TRIANGLE PARK, N.C. — Opioid death rates continue to rise, having reached 48,000 in 2017. Opioid use disorder medications can cut a patient’s risk of death in half. Requiring individuals to obtain health plan approval before being able to fill a prescription for these live-saving medications can create unnecessary barriers to accessing care. A new study in the Journal of the American Medical Association finds that the percentage of Medicare plans that required prior authorization for the most commonly prescribed medication to treat opioid addiction — buprenorphine-naloxone — decreased dramatically from 2017 to 2019, falling from 88 percent to 3 percent for brand name buprenorphine-naloxone and 96 percent to 0 percent for generic buprenorphine-naloxone.1
“Although Medicare has significantly reduced prior authorization for opioid use disorder medications, it is still in common use in Medicaid and private health plans,” explained Tami Mark, lead author of the paper and senior director of behavioral health financing and quality measurement at RTI International, a non-profit research institute. “Stigma and misconceptions about addiction may underlie the greater hoops that patients must jump through to access effective addiction treatment.”
In 2018, the Centers for Medicare & Medicaid Services (CMS) implemented a new requirement that Medicare drug plans limit the use of prior authorization. CMS cited the Food and Drug Administration (FDA) labeling change that emphasized the need to minimize barriers to access of opioid use disorder medications as a motivation for their new policy. The policy changes likely caused plans to remove prior authorization.
“The study has critical implications,” said Ellen Weber, vice president of Health Initiatives at the Legal Action Center, a non-profit law and policy organization that is working with RTI on this initiative. “This study suggests that clear guidance from CMS could immediately and significantly reduce those barriers in the Medicaid program. In the midst of the worst opioid epidemic in our nation’s history, the imperative to increase access to care is clear and pressing. At present, 35 state Medicaid programs still include prior authorization requirements for buprenorphine, and 40 states impose prior authorization for some or all forms of buprenorphine-naloxone.”
To determine Medicare coverage, RTI analyzed formulary files for standalone Medicare Part D and Medicare Advantage prescription drug plans for the 2017 through 2019 plan years. Formulary files indicate whether a Part D plan covers a medication and whether a medication requires prior authorization. Branded buprenorphine-naloxone, generic buprenorphine-naloxone, and generic buprenorphine monotherapy were examined to determine the number of plans that covered each product and required prior authorization.
Study collaborators and funders include the Laura and John Arnold Foundation, which is managed by Arnold Ventures, and the Legal Action Center (LAC).
1Note: Prior authorization is coded as present if it was used on all forms of buprenorphine/naloxone. Buprenorphine/naloxone can be provided as a tablet or a film. If there was prior authorization on the tablet form, but not the film form, it was coded as not having prior authorization.