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Study reveals increased restrictions on coverage of buprenorphine for Medicare Part D plans

Study reveals increased restrictions on coverage of buprenorphine for Medicare Part D plans

By Dr. Jessica Badichek, PharmD

A recent study published in JAMA, the Journal of the American Medical Association, summarized findings on the coverage of buprenorphine under Medicare Part D. Buprenorphine and buprenorphine combined with naloxone is one of the key medications used in medication-assisted treatment for opioid use disorder. Buprenorphine has often been underutilized due to several barriers including insurance coverage and physician requirements for prescribing.

This study found that from 2007 to 2018, prior authorization restrictions for Medicare part D plans increased from 11% to 65%. This represents a major increase in payment issues that may delay or disrupt treatment for vulnerable opioid use disorder patients that often require treatment right away to avoid withdrawal symptoms. Prior authorization can be a lengthy process to determine whether or not a medication will be covered by insurance. Patients that experience treatment delays due to insurance coverage may be at risk for relapse. Therefore, a prior authorization process may be a major barrier to timely and effective treatment.

This study also concluded that 93-100% of insurance plans covered prescription opioids without restrictions. Comparatively, buprenorphine coverage without restriction dropped from 89% in 2007 to 35% in 2018. This analysis may highlight the inaccurate misconceptions payors and healthcare practitioners may have regarding medication-assisted treatment and opioid use disorder. Due to the nature of opioid medications, any patient taking an opioid medication may be at risk for opioid misuse and addiction.

Therefore, there is a lack of consistency in the coverage of medications. A patient may be prescribed an opioid medication for pain and have this treatment covered. That same patient may develop addiction to the opioid medication prescribed and seek medication-assisted treatment. However, the medication-assisted treatment may not be covered or may require a prior authorization that delays treatment and risks withdrawal symptoms and relapse.

Offering reasonable cash pricing and payment programs for these medications may be a possible approach to this issue. However, insurance carriers, especially the Centers for Medicare and Medicaid services need to address this problem. If opioid medications that can put patients at risk for addiction are covered, then the medications such as buprenorphine used to treat that addiction should be covered as well.

Help & Resources:
CDC Guide to Opioids
SAMHSA Treatment Near You
FDA Disposal of Unused Medications

Important Information: The information contained in this blog is meant for INFORMATIONAL PURPOSES ONLY. This information is not individual medical advice and does not substitute for the advice of your healthcare professional. Always ask your physician or healthcare professional for complete information regarding your care.

About the Author:
Dr. Jessica Badichek is the Director of Clinical Operations at CompreCareRx. With extensive knowledge of psychiatric therapeutics, substance use disorder therapies and pharmaceutical compounding, she is dedicated to providing optimal clinical care policies that focus on the needs of every individual patient. She has a passion for caring for those suffering from addiction and seeks to provide superior clinical care. She holds a Doctor of Pharmacy degree from Philadelphia College of Pharmacy and is a registered pharmacist.