From Health Plan Week

To Counter an Epidemic, National MCOs End Opioid-Addiction Drug Preauthorizations

Reprinted from HEALTH PLAN WEEK, the most reliable source of objective business, financial and regulatory news of the health insurance industry. Subscribe today!

March 13, 2017Volume 27Issue 9

On March 1, Aetna Inc. became the latest national managed care organization to voluntarily remove preauthorization requirements on all buprenorphine products for its commercial formularies. Buprenorphine is used to treat opioid withdrawal symptoms, but preauthorization requirements can create delays for patients who might not have days — or hours — to wait for paperwork to be filed (see box, p. 3).

Aetna will continue utilization reviews for the drug to help identify potential intervention opportunities, and quantity limits for the drug will remain in place, says Aetna spokesperson Matthew Clyburn. Preauthorizations were used partly to ensure the correct diagnosis. The change in policy was prompted by an investigation by New York Attorney General Eric Schneiderman (D). Other carriers have made similar moves.

In January, Schneiderman said Anthem, Inc. had voluntarily agreed to end its preauthorization policy for medication-assisted treatment (MAT) for opioid use disorder. Sherry Dubester, M.D., vice president of behavioral health and clinical programs at Anthem, says data indicated that the company’s preauthorization program was doing little to improve the quality of comprehensive care. The change is effective in all 14 states where Anthem operates a Blues plan (see story, p. 3).

Anthem’s agreement came several months after Cigna Corp. made a similar change, also prompted by Schneiderman. Previously, Cigna required providers to submit a prior approval form for MAT requests, which asked the providers — who had already received specific training regarding MAT — to answer numerous questions about the patient’s current treatment and medication history.

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The pre-authorization process, at times, took up to 72 hours to complete, and that could create a window for a patient to decide to go back to using opioids. “We realized the benefits of the prior-authorization process didn’t outweigh those risks,” says Doug Nemecek, M.D., chief medical officer for Cigna’s behavioral health business. The benefits included ensuring a correct diagnosis was made, he tells AIS Health.

Over the past year, Cigna has taken an enterprise-wide approach to address the opioid epidemic and improve opioid prescribing. In May, Cigna President and CEO David Cordani said the company would reduce opioid prescriptions by 25% by 2019. That would bring levels back to what they were in 2006, before the opioid crisis began.

Three FDA-approved medications used in MAT for opioid addiction get the most attention when it comes to insurers’ coverage decisions. MAT involves a combination of behavioral therapy with FDA-approved medications: methadone, buprenorphine (oral or implantable), buprenorphine in combination with naloxone (Suboxone), oral naltrexone and long-acting, injectable naltrexone (Vivitrol). The medications are not widely covered by insurance plans.

Last summer, Aetna began tapping its database to flag doctors whose opioid prescribing history went outside typical patterns. The carrier contacted nearly 1,000 providers who were in the top 1% of opioid prescribers in their specialty, according to an August article in the Washington Post.

“Our goal is to reduce supply, manage appropriate use, increase adoption of medication-assisted treatment, and reduce the rate of opioid-related overdoses, ER visits, and deaths,” Clyburn said in an email to AIS Health.

For the past 10 years, Cigna has had a program that monitors opioid and narcotic prescriptions to flag potential fraud and abuse, such as filling prescriptions at multiple pharmacies. Over the past year, that physician-education effort has grown to include prescription drug doses that could place a member at risk for an overdose or complication, says Nemecek. Moreover, opioid prescriptions combined with diagnoses of behavioral health issues such as depression could put someone at a higher risk for overdose or complications. Through algorithms, the company is alerting network providers to those risks, he says.

“This is a large issue that affects every community, and we can’t fix it alone,” says Nemecek. “But insurers play an important role in sharing data and in educating physicians and consumers about appropriate care for opioid use disorder, as well as [appropriate prescribing] for the treatment of acute and chronic pain.”

Governors Join Forces

It’s been a year since the National Governors Association’s (NGA) Health and Human Services Committee set out to develop a set of protocols for opioid prescribing modeled after a multifaceted program implemented by Blue Cross Blue Shield of Massachusetts.

During a panel at last year’s NGA meeting, Andrew Dreyfus, CEO of the Massachusetts Blues plan, described his company’s “breakthrough program,” which mandates prior authorization for certain opioid prescriptions and requires some patients to use a single drugstore for opioid prescriptions. It also urges physicians to offer a treatment plan that includes non-narcotic options. Three years after the program launched, opioid prescriptions in Massachusetts were cut by 21 million doses.

In July, 46 governors signed NGA’s Compact to Fight Opioid Addiction, which outlines steps to reduce inappropriate prescribing, improve the national understanding of opioid addiction and ensure a pathway to recovery for people suffering from addiction, according to a prepared statement from the NGA. It was the first time in a decade that governors joined forces to address an urgent national issue, according to an email from the organization.

On March 1, Maryland Gov. Larry Hogan (R) declared a state of emergency in response to the heroin, opioid and fentanyl crises impacting communities across his state and throughout the country. Hogan also announced $50 million in new funding to address the crisis.


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