Coverage and Management of
Medications for Treating Substance
Abuse in Health Plans
Constance M. Horgan, Sc.D.
Sharon Reif, Ph.D.
Dominic Hodgkin, Ph.D.
Deborah W. Garnick, Sc.D.
Elizabeth L. Merrick, Ph.D.
Institute for Behavioral Health, Schneider Institutes
The Heller School for Social Policy and Management
Brandeis University
AcademyHealth Annual Meeting, June 2006
Supported by NIDA (R01 DA10915) and NIAAA (R01 AA10869)
Why Consider Medications for
Substance Use Disorders?
• Important clinical advances in the
pharmacological treatment of addiction and
increasing availability of SA meds for consumers
• Prescription benefits can affect
– Access to medications for substance use disorders
– Cost of medications for substance use disorders
• Extent of restrictions influencing true availability
to consumers in private health plans is unknown
Institute for Behavioral Health
Research Questions
• Which medications are excluded from coverage or
placed on the costliest tier?
• How common are administrative controls, such as
prior authorization?
• What plan characteristics are associated with use
of each approach?
– More managed plans (e.g. HMO) vs. others
– Whether the plan contracts out for specialty
behavioral health (carve-out)
Institute for Behavioral Health
Study Overview
• Telephone survey of 368 health plans regarding
812 commercial managed care products for
2003; response rate = 83%
• Coordinated with RWJF’s Community Tracking
Study (CTS)
• Focus on provision of alcohol, drug, and mental
health services – administrative and clinical
modules; typically 2 respondents per health plan
• Designed to produce national estimates
• Survey administered by Mathematica Policy
Research
Institute for Behavioral Health
Research Domains
Administrative Module
•
Plan characteristics
•
Contract arrangements
•
•
•
•
Clinical Module
•
Screening and primary
care
Benefit design
•
Provider payment
methods
Entry into specialty
treatment
•
Specialty treatment
approaches
•
Quality assurance
•
Prescription drugs
Network management
Enrollment and
utilization
Institute for Behavioral Health
Measures of Medication Management
Approach to specific medications can include:
• Exclusion from coverage
• Highest tier coverage on 3-Tier formularies
– Tier 1: lowest co-payment, usually generic meds
– Tier 2: middle co-payment, usually preferred brands
– Tier 3: highest co-payment, non-preferred brands
• Prior authorization requirement
Institute for Behavioral Health
Medications Studied
Alcohol Dependence
Naltrexone (generic)
Revia (brand name naltrexone)
Antabuse (disulfiram)
Opioid Dependence
Suboxone (buprenorphine/naloxone)
Subutex (buprenorphine)*
Methadone**
* Subutex results paralled Suboxone results, so are not shown
**Methadone coverage examined in the context of treatment
services; it is not a covered benefit for 48% of private health plans
Institute for Behavioral Health
What is the Pattern of Exclusion and
3-Tier Usage for SA Medications?
100%
Revia
Naltrexone
Antabuse
Suboxone
14
Tiers 1 or 2
80%
Tier 3
52
Excluded
71
60%
55
92
40%
41
20%
28
0%
6
31
6
Percent of Plans
Institute for Behavioral Health
How Often is Tier 3 Used for SA
Medications? **if medication is covered
100
80
80
60
Revia
Naltrexone
Antabuse
Suboxone
44
40
28
20
2
0
Alcohol
Opiate
Percent of Plans with Medication on Tier 3
Institute for Behavioral Health
How Often is Prior Authorization Required
for SA Medications? **if medication is covered
20
Revia
Naltrexone
16
Antabuse
12
Suboxone
7
8
4
3
2
0
0
Alcohol
Opiate
Percent of Plans Requiring Prior Authorization
Insitute for Behavioral Health
What is the Coverage Pattern for Alcohol
Medications, by Contracting Arrangements?
Revia
100%
Naltrexone
Antabuse
29
80%
52
71
60%
75
81
93
51
40%
Tiers 1 or 2
Tier 3
Excluded
43
20%
17
29
19
5
9
te
rn
al
In
lty
ec
ia
Sp
te
rn
al
In
lty
ec
ia
Sp
te
rn
al
5
In
ec
ia
lty
0%
Sp
19
Percent of Plans
Institute for Behavioral Health
What is the Coverage Pattern for Alcohol
Medications, by Product Type?
Revia
100%
Naltrexone
Antabuse
Tiers 1 or 2
80%
Tier 3
Excluded
43
53
59
60%
90
94
75
72
24
27
67
93
40%
50
38
38
20%
9
0%
4
7
HMO POS PPO
9
4
33
7
HMO POS PPO
Percent of Plans
HMO POS PPO
Institute for Behavioral Health
What is the Coverage Pattern for Opiate Medications
by Contracting Arrangements and Product Type?
Suboxone
100%
7
10
18
8
25
80%
46
57
51
Tiers 1 or 2
Tier 3
Excluded
60%
63
69
40%
20%
39
36
46
19
6
0%
Specialty
Internal
HMO
POS
PPO
Percent of Plans
Institute for Behavioral Health
Conclusions
• Exclusions
– Rare for alcohol dependence medications
– Buprenorphine excluded by 1/3 of products
– Little variation by product type or contracting
• Tier 3
– Common for alcohol dependence medications
– Frequent for buprenorphine
– Little variation by product type or contracting
• Prior authorization
– Used rarely
– More likely buprenorphine
– Less likely for specialty contracts
Center for Behavioral Health
Implications
• Access to SA medications is limited depending
on prescription benefit structure
• Inclusion on formularies is necessary for use of
SA medications to be a viable treatment option
• Placement of SA medications on higher tiers
may financially restrict access to SA medications
for consumers in private plans
• Prior authorization, common in public plans, is
rarely used in private plans
Center for Behavioral Health