As the opioid abuse crisis continues to wreak havoc across the country, patient advocates are growing increasingly critical of how health insurers cover--or fail to cover--substance use disorder treatments.
One such coverage barrier is prior authorization. These rules can result in patients waiting days or weeks for opioid withdrawal treatments such as Suboxone, which opens the door for relapses, FierceHealthPayer has reported.
Another issue is the “fail-first” policy many insurers use that requires patients to use an insurer-preferred treatment first, and only if that fails will they receive approval for the treatment ordered by a patient’s doctor, the Cincinnati Enquirer and USA Today report. This tactic can prove dangerous for recovering addicts, one advocate argues.
"Failing first means you’re going to relapse and overdose," said Emily Feinstein, director of health law and policy for the National Center on Addiction and Substance Abuse.
Feinstein’s organization published a study this past summer that said no state’s 2017 benchmark plan provides comprehensive coverage for addiction treatment, and more than two-thirds violated the Affordable Care Act’s coverage mandates for addiction treatment benefits.
The National Council for Behavioral Health believes every plan should cover all FDA-approved medications for addiction treatment, Vice President of Addictions Becky Vaughn told the publications. In New York, the attorney general successfully sued to make insurers design plans in compliance with the law.
Some insurers, though, are striving to be on the front lines of the fight against the opioid epidemic. Cigna, which is already providing claims data to American Society of Addiction Medicine, also has no fail-first policies for addiction treatment, Chief Medical Officer for Behavioral Health Douglas Nemecek, M.D., told the publications. Some Cigna plans require prior authorization for Suboxone, but none require it for the treatment Vivitrol, he added.