Anthem has reached an agreement with New York State Attorney General Eric T. Schneiderman to end its policy of requiring prior authorization for medication-assisted treatment (“MAT”) for opioid use disorder.
The agreement includes Empire BlueCross BlueShield (“BCBS”), which insures over four million New Yorkers, and resolves Attorney General Schneiderman's investigation of prior authorization practices and network adequacy for MAT treatment.
This policy change will apply not only to most Anthem members in New York, but nationally as well.
“We're facing an opioid crisis in New York and around the country – and we should be doing whatever we can to make lifesaving treatments accessible to those suffering from addiction,” said Attorney General Schneiderman. “I am pleased that this is the second national settlement my office has reached with major insurers to remove hurdles to opioid addiction treatment. While we've made progress, there are too many still suffering. We're committed to continue working with health insurers across the country to eliminate barriers to lifesaving opioid addiction treatments.”
Anthem required providers to submit a prior approval form for MAT coverage requests, which required the providers – who already had received specific training regarding MAT and federal authorization to prescribe these drugs – to answer numerous questions about the patient's current treatment and medication history. The Attorney General's investigation revealed that Empire BCBS denied nearly eight percent of the overall requests for coverage of MAT in 2015 and the first half of 2016. According to the Attorney General, this subsequently caused significant delays in patients obtaining treatment for addiction – or patients never obtaining the treatment at all.
In contrast to its policy for drugs to treat opioid use disorder, Empire BCBS does not require prior authorization for the majority of drugs it covers for medical conditions. In particular, Empire BCBS does not require prior authorization for powerful opioids, including fentanyl, morphine, tramadol, and oxycodone, when prescribed for pain. Attorney General Schneiderman said in a statement that these disparities were not consistent with the New York and federal mental health parity laws, which require health plans to cover mental health and substance use disorder treatment the same way they cover treatment for physical conditions.
Under the agreement, Empire BCBS will launch an initiative to expand access to MAT for members in its New York service area. Empire BCBS will conduct provider outreach and education regarding the benefits of MAT, informing qualified health care providers how they can obtain certification from the Substance Abuse and Mental Health Services Administration (“SAMHSA”) to prescribe buprenorphine and buprenorphine/naloxone as part of MAT for opioid dependence. Empire BCBS will provide the Attorney General with a list of MAT providers who have joined its network as a result of this initiative.
Unlike methadone treatment, which must be administered in a highly structured clinic, MAT medications, usually containing buprenorphine and naloxone, may be prescribed or dispensed in physicians' offices to treat opioid use disorder, provided the treating physician has obtained the appropriate certification and has been issued a special Drug Enforcement Administration (“DEA”) license. In addition to the medication component, psychosocial therapy and management of medical issues also are recommended components of MAT to treat opioid use disorder.
The Centers for Disease Control and Prevention considers MAT a proven, effective treatment for individuals with an opioid use disorder. MAT is supported and endorsed by the CDC, the Substance Abuse and Mental Health Services Administration (“SAMHSA”), the American Society of Addiction Medicine (“ASAM”), the New York State Office of Alcoholism and Substance Abuse Services (“OASAS”), and the New York City Department of Health and Mental Hygiene (“NYCDOHMH”) as a treatment for opioid addiction.
Anthem's policy change follows efforts by both New York State and the federal government to increase access to MAT for opioid use disorder. New York State recently enacted legislation prohibiting insurers from requiring prior authorization for emergency supplies of MAT medications and also removed prior authorization for Medicaid members seeking MAT for opioid use disorder, while the federal government increased the maximum number of patients that MAT-certified providers can treat at one time from 100 to 275 and now permits qualified nurse practitioners and physician assistants to prescribe MAT drugs.
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Victoria Spears
Victoria Prussen Spears is senior vice president of Meyerowitz Communications Inc., a law firm marketing communications consulting company. A graduate of Sarah Lawrence College and Brooklyn Law School, Ms. Spears was an attorney at a leading New York City law firm before joining Meyerowitz Communications. She may be contacted at [email protected].