Healthcare providers and patients in Pennsylvania will no longer need to seek advance approval to prescribe medication-assisted treatment for substance use disorder thanks to an insurer agreement struck Friday.
Seven of the state's major health insurance companies—Aetna, Capital Blue Cross, Geisinger, Highmark, Independence Blue Cross, UPMC and United Healthcare—have agreed to remove prior authorization requirements for substance use disorder treatments, according to the American Medical Association and the Pennsylvania Medical Society.
Health experts estimate the move could give thousands of Pennsylvanians access to the treatments.
"We have long advocated for the removal of prior authorization and other barriers to increase access to medication-assisted treatment (MAT) for substance use disorders," AMA President-elect Dr. Patrice A. Harris said in a written statement. "The leadership shown by the governor and his administration to reach this agreement should act as a call for all states to demonstrate that they support patients' access to care over needless administrative burdens."
Under the agreement, health insurers will cover at least one buprenorphine-naloxone product; methadone; injectable and oral forms of naltrexone, which blocks the effects of opioids; and the nasal form of the overdose-reversal drug naloxone without pre-approval. Insurers also will provide MAT coverage at the lowest patient cost tier on the plan's pharmacy benefit.
The agreement will apply to individual, small-group and large-group fully insured plans. Employer-funded plans are not included in this agreement.
Pennsylvania Gov. Thomas Wolf's office said the agreement stems from a summit held last fall between insurers, the departments of Drug and Alcohol Programs, Health and Human Services and Insurance. The move aligns prior authorization limits of the large commercial plans for MAT access with those already used by both the state's Medicaid fee-for-service and managed-care programs.
"It is vital we take all possible steps to make sure patients are receiving the most appropriate treatment for their pain, while at the same time appropriately managing and monitoring the risks associated with opioids," said Dr. Rachel Levine, secretary of the state's Health Department, in a statement.
Advocates have long argued for removing barriers to treatment, saying they have limited or delayed access to treatment in the middle of an opioid epidemic. More than 70,000 people died in 2017 due to the opioid crisis.
Friday's announcement is the latest in a number of similar policy changes taken by commercial insurers in response to the opioid crisis in recent years. In 2016, Cigna became the first large insurer to eliminate prior authorizations for MAT. Anthem followed suit the next year. New York Attorney General Eric Schneiderman had launched an investigation to uncover barriers to treatment due to prior authorization policies before those announcements.
Pennsylvania has been one of the states hardest hit by the opioid crisis. The state had the fifth-highest rate of drug overdose mortality in 2016 with 37.9 deaths for every 100,000 persons and had the third-highest total number of overdose deaths at 4,627, according to the Centers for Disease Control and Prevention.
