(Harrisburg, PA - Insurance News 360) – In October, Gov. Tom Wolf’s administration came to agreement with commercial insurers in Pennsylvania to align prior-authorization processes for opioid prescriptions to protect patient health and safety while ensuring patients have unrestricted access to medication-assisted treatment (MAT) when needed to battle opioid addiction.
“It is vital we take all possible steps to make sure patients are receiving the most appropriate treatment for their pain, while at the same time appropriately managing and monitoring the risks associated with opioids,” Department of Health Secretary Dr. Rachel Levine said. “Medication-assisted treatment is an effective, evidence-based treatment to help those with the disease of addiction to opioids and this step by private insurers allows more people with opioid use disorder to be able to access this form of treatment. Treatment works and recovery is possible for those who are battling this disease.”
The announcement, made Oct. 12, followed a summit of Pennsylvania’s largest health insurers and the Medicaid managed care program, the departments of Drug and Alcohol Programs, Health, and Human Services, and the Insurance Department. The summit was part of the administration’s ongoing effort to battle the opioid crisis.
Insurers agreeing to the guidelines include Aetna, Capital BlueCross, Geisinger, Highmark, Independence Blue Cross, UPMC, and United Healthcare.
“I want to thank Governor Wolf for his continued leadership on battling the opioid crisis in our state, and our insurers for coming to the table to find ways to cover appropriate treatment when it is needed, and for working with our medical providers to properly manage and monitor this treatment,” Insurance Commissioner Jessica Altman said.
This move closely aligns commercial insurance prior-authorization requirements for opioid prescriptions and access to MAT with requirements used by both Medicaid fee-for-service and managed care programs. The requirements were implemented earlier this year by the Department of Human Services.
These guidelines apply to individual, small group, and large group fully insured plans. Self-funded plans, where employers provide health care coverage administered by a third party, are regulated by the federal government and are not included in this agreement.
They implement thresholds for prior authorization for long- and short-acting opioids, morphine milligram equivalents (MME) and exceptions for active cancer, sickle cell crisis, and palliative care/hospice patients. Some insurers are phasing in their alignment with many of the guidelines. Patients should consult with their insurer to find out how these guidelines are being incorporated into their specific health plan.
Under this agreement, commercial insurers will cover MAT without prior authorization in the following ways:
• Coverage of at least one Buprenorphine/naloxone combination product
• Coverage of Methadone as MAT
• Coverage of injectable and oral Naltrexone
Commercial insurers have also committed to coverage of at least one form of nasal naloxone without quantity limits. The guidelines also provide that MAT will be covered at the lowest patient cost tier on the plan’s pharmacy benefit, as applicable.
Source: Pennsylvania Department of Insurance.