Understand how we got here — and how to move forward.


September 19, 2017

Some insurers restrict coverage of less-addictive opioid alternatives, analysis finds

Daily Briefing

Amid the U.S. opioid misuse epidemic, some Medicare insurers appear to be restricting coverage for less-addictive pain medications, potentially leading to greater use of lower-cost generic opioids, according to an investigation by ProPublica and the New York Times.

Your top resources for combatting the opioid epidemic in one place

Federal and state officials in recent years have taken aim at drugmakers, pharmaceutical distributors, pharmacies, and providers for their alleged roles in contributing to the opioid misuse epidemic. But, according to ProPublica and the Times, insurers and pharmacy benefit managers until recently had largely gone unexamined, and some experts say they play a key role in determining which pain management treatments patients can affordably access.

To examine insurers' and pharmacy benefit managers' roles in the ongoing epidemic, ProPublica and the Times, analyzed Medicare prescription drug plans that covered 35.7 million beneficiaries in the second quarter of 2017.

Investigation highlights role insurers play in determining access 

The analysis found that nearly every plan examined covered common opioids, with only a few requiring that beneficiaries receive prior approval—but several plans either did not cover or required prior approval for less-addictive alternatives.

For instance, the analysis found only about 33 percent of covered beneficiaries had access to Butrans, a skin patch used to treat pain that contains the less-addictive drug buprenorphine. Further, the analysis showed each drug plan that covered non-addictive lidocaine patches had prior approval requirements. 

According to the analysis, insurers also imposed restrictions for some medication-assisted addiction treatments. For instance, in an analysis of drug plans covering 33.6 million beneficiaries, two-thirds required prior authorization for the addiction treatment drug Suboxone, and several pharmacists and providers said even when plans do not require prior authorization, the out-of-pocket costs often render such drugs unaffordable for patients.

Christopher Jones—a senior policy official at HHS, which is studying whether insurers have made opioids more accessible than alternative pain treatments—said early data from HHS also suggest some plans may be placing more restrictions on alternative pain management treatments than opioids.

Tom Frieden, former head of CDC, said that most insurance companies had "not done what they need to do to address" the opioid epidemic. Frieden said currently it is easier for many patients to access opioids than substance misuse treatment.

Leo Beletsky, an associate professor of law and health sciences at Northeastern University, argued that insurers were "one of the major causes of the crisis" because they give providers an incentive to use lower-cost opioids.

Insurers respond

When asked about specific drug policies, insurers acknowledged that in some cases they do require approval for some non-opioid alternatives. For instance, Anthem said its members must meet certain requirements before it will cover Lyrica, a non-opioid, brand-name drug that treats nerve pain, although the insurer said members can apply for exceptions.

According to ProPublica and the Times, UnitedHealthcare has placed Lyrica on its highest cost tier, and requires patients to first try other drugs.

Matthew Wiggin, spokesperson for UnitedHealthcare, said the company's rules and preferred drug list "are designed to ensure members have access to drugs they need for acute situations, such as post-surgical care or serious injury, or ongoing cancer treatment and end of life care."

Insurers highlight efforts to combat opioid misuse

Insurers say they have taken many steps to combat the opioid misuse epidemic, such as monitoring provider prescribing patterns and patients' opioid prescriptions.

In fact, several major insurers recently have reported declines in opioid prescriptions. For instance, in August both Anthem and UnitedHealth Group announced opioid prescriptions had fallen among their members, with Anthem reporting a 30 percent drop and UnitedHealth Group's OptumRx reporting an 82 percent decline in prescriptions above CDC's recommended dose of 50mg morphine-equivalent dose per day for first-fill acute prescriptions.

Mark Friedlander, CMO of Aetna Behavioral Health, said Aetna also has taken a strong stance against opioid misuse. "We have a very comprehensive approach toward identifying in advance who might be getting into trouble, and who may be on that trajectory toward becoming dependent on opioids," he said.

Wiggin also said UnitedHealthcare is working to reduce long-term use of opioids, saying, "All opioids are addictive, which is why we work with care providers and members to promote non-opioid treatment options for people suffering from chronic pain" (Thomas/Ornstein, ProPublica/New York Times, 9/17).

Reduce opioid misuse and abuse with our new report

Opioid misuse and abuse is one of the most pressing public health issues in the U.S., and hospitals and health systems are on the front lines. Currently, most health systems focus their opioid management efforts on select medical specialties.

This report outlines three imperatives to guide hospitals and health systems in their efforts to reduce the impact of inappropriate opioid prescribing and misuse.

Get the Report

Have a Question?


Ask our experts a question on any topic in health care by visiting our member portal, AskAdvisory.