Aetna, one of the nation鈥檚 largest insurance companies, will remove a key barrier for patients seeking medication to treat opioid addiction. The change will take effect in March and apply to commercial plans, a company spokeswoman confirmed, and will make it the third major insurer to make the switch.
Specifically, Aetna will stop requiring doctors to seek approval before prescribing particular medications 鈥 such as Suboxone 鈥 that are used to mitigate withdrawal symptoms, and typically given along with steady counseling. The insurance practice, called 鈥,鈥 can result in delays of hours to days in getting a prescription filled.
The change comes as addiction to opioids, which include heavy-duty painkillers and heroin, still sweeps the country. More than died from overdosing on these drugs in 2015, the most recent year for which statistics are available. And it puts Aetna in the company of Anthem and Cigna, which both recently dropped the prior authorization requirement for privately insured patients across the country. Anthem made the and Cigna .
Both companies took the step after facing investigation with New York鈥檚 attorney general, whose office was probing whether their coverage practices unfairly barred patients from needed treatment. They made this adjustment as part of larger settlements.
It sounds like just a technicality 鈥 a brief delay before treatment. But addiction specialists say this red tape puts people鈥檚 ability to get well at risk. It gives them a window of time to change their minds or go into withdrawal symptoms, causing them to relapse.
鈥淚f someone shows up in your office and says, 鈥業鈥檓 ready,鈥 and you can make it happen right then and there 鈥 that鈥檚 great. If you say, 鈥楥ome back tomorrow, or Thursday, or next week,鈥 there鈥檚 a good chance they鈥檙e not coming back,鈥 said Josiah Rich, a professor of medicine and epidemiology at Brown University and doctor at Providence-based Miriam Hospital, who frequently treats patients with opioid addictions. 鈥淭hose windows of opportunity present themselves. But they open and close.鈥
As these major carriers drop the requirement, treatment specialists hope a trend could be emerging in which these addiction meds become more easily available. In New York, for instance, the attorney general鈥檚 office will be following up with other carriers who still have prior authorization requirements, an office spokesperson said. The office would not specify which carriers it will next examine.
Meanwhile, though little research pinpoints precisely how widespread this coverage practice is for drugs that treat opioid addiction, experts say it鈥檚 a fairly common practice.
鈥淛ust think of any big health insurance company that hasn鈥檛 recently announced they鈥檙e doing away with this, and it鈥檚 a pretty safe bet they鈥檝e got prior authorization in place,鈥 said Andrew Kolodny, a Brandeis University senior scientist and the executive director of Physicians for Responsible Opioid Prescribing, an advocacy group.
Aetna will stop requiring doctors seek approval before prescribing particular medications such as Suboxone. (Wikimedia Commons)
How does the problem manifest? Take Boston Medical Center, located in a region that鈥檚 been particularly hard hit by opioid addiction. Doctors there wanted to launch an urgent care center focused on this patient population. Less than a year old, the program鈥檚 treated thousands of people.
But prior authorization requirements have been intense, said Traci Green, an associate professor at Boston University鈥檚 School of Medicine and deputy director of the hospital鈥檚 injury prevention center. To help people get needed care 鈥 before it was too late 鈥 the center hired a staffer devoted specifically to filling out all the related insurance paperwork.
鈥淚t was like, 鈥楾his is insanity,鈥欌 Green said, adding that 鈥渘avigating the insurance was a huge problem鈥 for almost every patient.
But defenders of the requirement maintain that such controls have value. Insurance plans using prior authorization may view it as a safeguard when prescribing a potentially dangerous drug. 鈥淸It鈥檚] not a tool to limit access. It鈥檚 a tool to ensure patients get the right care,鈥 said Susan Cantrell, CEO of the Academy of Managed Care Pharmacy, a trade group.
Other large insurance carriers 鈥 such as and 鈥 list on their drug formularies a prior authorization requirement for at least some if not all versions of anti-addiction medication. A spokesperson from Humana said the practice is used 鈥渢o ensure appropriate use.鈥
Also, though, it is generally agreed that the practice is used to control the prescribing of expensive medications. Per dose, the cost of these drugs varies based on brand and precise formulation, but it can go as high as almost $500 for a 60-pack dose, which can last a month.
Regardless of intent, critics say, those extra forms and hoops do make it more difficult for patients in need to get these medications 鈥暵爑ltimately, they say, doing more harm than good.
鈥淚f you would like a physician to not do a particular treatment, put a prior authorization in front of it,鈥 Rich said. 鈥淭hat鈥檚 what they鈥檙e used for.鈥
Meanwhile, addiction treatment advocates and health professionals are hoping to build on what they see as new momentum.
Earlier this month, the American Medical Association to the National Association of Attorneys General, calling for increased attention to insurance plans that require prior authorization for Suboxone or other similar drugs.
has written to health plans in the state, asking they end prior authorization for addiction treatment. New York has also heard from other states interested in tackling the issue, the attorney general spokesperson said. And another project, called Parity Track, is soliciting complaints from consumers.
They鈥檙e arguing based on a requirement that insurance plans, thanks to so-called 鈥減arity laws,鈥 must cover addiction treatment, and cover it at the same level as they do other kinds of health care.
The prior authorization requirement 鈥渄oesn鈥檛 meet the sniff test for parity,鈥 said Corey Waller, an emergency physician who chairs the American Society of Addiction Medicine鈥檚 legislative advocacy committee. 鈥淚t鈥檚 a first-line, Food and Drug Administration-approved therapy for a disease with a known mortality. Every other disease with a known mortality 鈥 the first-line drugs are available right away.鈥
But the justification for legal cases like New York鈥檚 could get weaker. The 2010 health law, which lawmakers are working to repeal, included requirements that mental health and addiction treatment be considered an 鈥.鈥 If that disappears, robust coverage for addiction could be less widely available, several noted.
Meanwhile, the stakes are substantial, Rich said. He recalled a patient who was taking a version of buprenorphine 鈥 the active ingredient in Suboxone 鈥 who had a brief relapse with heroin. That led to complications in the paperwork for renewing his prescription for treatment.
鈥淣ow he鈥檚 out of the office, in the street, using more,鈥 Rich said of that case. 鈥淚ncumbent upon [effective treatment] is the ability to get people started right away. If there鈥檚 prior authorization? It鈥檚 infuriating.鈥