Study examines insurance barriers to access opioid addiction medication

In 2021, more people died from opioid overdoses in the U.S. than any other year in history, according to data from the U.S. Centers for Disease Control and Prevention.

However, a new University of Central Florida study recently published in Health Affairs shows that one of the most effective medications for treating opioid addiction is one of the least covered by insurance plans often used by patients with substance use disorder.

Researchers found that although most plans covered the immediate-release sublingual form of buprenorphine, extended-release buprenorphine injections were covered by less than half of commercial plans and less than a fifth of Medicare Advantage Plans. Furthermore, while most Medicaid plans did cover it, more than a third presented a barrier by requiring prior authorization before prescription.

The study's lead author, Barbara "Basia" Andraka-Christou, says her key passion in research is trying to understand how to expand access to these life-saving treatments.

"Approximately 20% of people actually use buprenorphine or another similar medication called methadone for treatment of opioid-use disorder," she says. "Most people don't get any treatment, or if they do get treatment, they're getting something that's less effective. Unfortunately, there have been a lot of barriers to accessing it, and some of those have been either lack of insurance coverage or various prior-authorization requirements."

Buprenorphine can be prescribed by any clinician licensed by the Drug Enforcement Administration and comes in two overall forms: an oral immediate release version that is taken daily or a monthly extended-release intramuscular injection. Since some of the oral versions of the medication are available in generic form, they tend to be the cheaper option. The injection is newer and still under patent, making it the more expensive option.

How the research was performed

Andraka-Christou, an associate professor in the School of Global Health Management and Informatics at UCF, teamed up with Thuy Nguyen from the University of Michigan, W. David Bradford from the University of Georgia and Kosali Simon from Indiana University to examine Medicaid, Medicare Advantage and commercial insurance formulary files to compare insurance-imposed restrictions for buprenorphine from 2017-21.

They studied factors like insurance coverage, prior-authorization requirements, and other potential access barriers like step therapy and quantitative limits across commercial providers, Medicaid, and Medicare.

"Medicaid covers about a third of people in the U.S. with opioid-use disorder and Medicare covers both the elderly and disabled populations," she says. "That's important because among older Americans, the rates of opioid overdoses have also been increasing. Because people flow in and out of different types of insurance, it's very important to look at all insurance sectors."

What Andraka-Christou and her team found were stark differences in coverage and prior authorization barriers depending on the form of buprenorphine requested. Nearly all plans covered at least one form of immediate-release buprenorphine in 2021, and prior-authorization requirements and quantity limits gradually decreased for immediate-release buprenorphine.

The intramuscular, extended-release injection was subject to the most variance by insurer type. Their research determined that Medicare and commercial insurance were less likely to cover the cost of the buprenorphine injection—with only 46% of commercial plans and 19% of Medicare Advantage plans covering it—as compared to Medicaid. On the other hand, most Medicaid plans covered the extended-release version in 2021, although 37% still required prior authorization.

Despite the oral version now being largely covered by insurers, Andraka-Christou says there is a downside in that it's easier for opioid-use disorder patients to relapse if they skip doses. With the monthly intramuscular injection, that is less likely to happen.

"The reason prior-authorization requirements are a problem is that someone with an addiction may have a short window of time during which they're willing to go and get treatment," Andraka-Christou says.

"From a public health standpoint, it's very important to not have prior-authorization requirements for these types of medicines. The injection is also very expensive because it's still on patent, so those requirements probably exist to cut costs. However, if someone had to wait days for the injection and has an overdose in that timeframe, then it might be less costly to not require prior authorization."

The barriers related to the oral version of buprenorphine have been a topic of conversation in U.S. healthcare for a while, but Andraka-Christou's team found that prior-authorization requirements for oral versions are minimal today compared to 10 years ago. With this new finding, she urges researchers, advocates and policymakers to shift their attention to the intramuscular injection version and work on addressing those barriers.

"I think providing access to life-saving treatment needs to be a priority for policymakers and community advocates, and that's where my passion comes from," Andraka-Christou says.

"The fact is that we have this ongoing, horrific crisis, but we also have tools like buprenorphine and methadone that could cut the risk of overdose deaths in half if they weren't so underused. State lawmakers could help lead this effort by requiring insurers to cover extended-release buprenorphine without prior authorization."