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.