All medication treatments for opioid addiction argued to be 'essential' insurance benefit

As opioid overdoses continue to rise across the country, providers are battling large insurers and pharmacy benefit managers that argue coverage of treatments for people with opioid addictions should be left up to the payers' discretion.

More than 28,600 people died in 2014 as the result of overdoses from prescription painkillers, heroin and other opioids, according to a recent analysis from the Centers for Disease Control and Prevention.

Numerous hospital associations, psychiatrists, primary-care physicians, executives at drug-abuse treatment centers and recovering opioid addicts recently submitted comments to the CMS urging that all health plans sold on the federal exchange cover medications that help overcome substance abuse.

The Affordable Care Act requires health insurers to cover 10 essential health benefits, including prescription drugs and substance-use disorder services. But it has been unclear whether plans on the federal marketplace must cover the full range of medication-assisted treatment, or MAT. Many commercial insurers pay for MAT, a therapy in which people combine medication with counseling to reduce their craving for opioids.

The Substance Abuse and Mental Health Services Administration and the National Institute on Drug Abuse have found MAT to be effective for people suffering from opioid addiction. The NIDA said MAT “increases patient retention and decreases drug use, infectious-disease transmission and criminal activity,” and it also saves money by keeping people out of hospitals and outpatient centers.

But some providers and patient advocates say insurers have instituted high copays and other barriers that result in inadequate coverage and access to the treatment.

Methadone and buprenorphine, the two most common drugs used in MAT, could annually cost someone thousands of dollars out of pocket.

SAMHSA officials also have argued there are misconceptions and stigmas associated with addicts and MAT, which could make treatment harder to access.

Travis Simerly and his wife are MAT patients who take methadone daily, according to Simerly's comments to the CMS. He wrote that his insurance company, Blue Cross and Blue Shield of Tennessee, denied their claim because the company covers only buprenorphine for addiction treatment. Simerly called the coverage discrepancy a “farce” and said all MAT drugs should be held to the same benefits standards. Blue Cross did not immediately respond for comment.

“Our addiction treatment is by far our largest medical expense, and for it to not be covered by the insurance that we are required by law to have is nothing more than a proverbial kick in the teeth,” Simerly wrote.

Dozens of individual physicians submitted letters asking the CMS to mandate that all federal health plans fully cover MAT as part of the essential health benefits.

“There is clinical consensus that MAT is the most effective treatment for opioid addiction,” said Dr. Shelly Greenfield, a psychiatrist at Harvard Medical School and McLean Hospital in Belmont, Mass. “The use of medications reduces opioid use and overdose rates, and helps retain people in treatment longer, which is associated with better outcomes.”

But the country's largest health insurers, PBMs and lobbying groups want the CMS to punt the proposal. America's Health Insurance Plans, the Blue Cross and Blue Shield Association, the Pharmaceutical Care Management Association, Express Scripts Holding Co., CVS Health Corp. and UnitedHealthcare said they shared the federal government's concern over the “devastating effect of opioid abuse,” but they argued they should not be forced to pay for specific treatments that could curb the problem.

“We are concerned that by mandating specific benefits within an (essential health benefits) category, CMS may establish a precedent of imposing essential health benefit mandates in the future,” Blue Cross and Blue Shield wrote. “Requiring plans to cover specific drugs within a category and class would conflict with this carefully established balance between coverage mandates and affordability, which in turn would lead to increases in premiums at a time when CMS is seeking to ensure that consumers have access to affordable coverage and that there is stability in the market.”

The companies and groups said the government should instead rely on individual insurers and their pharmacy and therapeutics committees to determine coverage for specific drugs.

However, the Association for Community Affiliated Plans—the trade group that represents small safety net health plans that cover many low-income people—disagreed with the large players, saying the industry should be prodded to fully cover MAT.

“ACAP plans are cognizant of the opioid addiction epidemic and are investing in efforts to address opioid abuse,” the organization said. “We are supportive of CMS adding MAT to the essential health benefits.”