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 InstitutesThe Heller School for Social Policy and ManagementBrandeis University

AcademyHealth Annual Meeting, June 2006Supported 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

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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)

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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

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Research Domains

Administrative Module• Plan characteristics

• Contract arrangements

• Benefit design

• Provider payment methods

• Network management

• Enrollment and utilization

Clinical Module• Screening and primary

care

• Entry into specialty treatment

• Specialty treatment approaches

• Quality assurance

• Prescription drugs

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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

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Medications Studied

Alcohol DependenceNaltrexone (generic)Revia (brand name naltrexone)Antabuse (disulfiram)

Opioid DependenceSuboxone (buprenorphine/naloxone)Subutex (buprenorphine)*Methadone**

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* 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

What is the Pattern of Exclusion and 3-Tier Usage for SA Medications?

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6 6

31

41

28

55

52

92

71

14

0%

20%

40%

60%

80%

100%

Tiers 1 or 2

Tier 3

Excluded

Revia Naltrexone Antabuse Suboxone

Percent of Plans

How Often is Tier 3 Used for SA Medications? **if medication is covered

44

2

28

80

0

20

40

60

80

100

ReviaNaltrexoneAntabuse

Suboxone

Institute for Behavioral HealthPercent of Plans with Medication on Tier 3

Alcohol Opiate

How Often is Prior Authorization Required for SA Medications? **if medication is covered

0

3

7

2

0

4

8

12

16

20

Revia

Naltrexone

Antabuse

Suboxone

Insitute for Behavioral Health

Percent of Plans Requiring Prior AuthorizationAlcohol Opiate

519

519

9

43

51

29 17

52

29

71 7581

93

0%

20%

40%

60%

80%

100%

Specia

lty

Inte

rnal

Specia

lty

Inte

rnal

Specia

lty

Inte

rnal

Tiers 1 or 2Tier 3Excluded

What is the Coverage Pattern for Alcohol Medications, by Contracting Arrangements?

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Revia Naltrexone Antabuse

Percent of Plans

What is the Coverage Pattern for Alcohol Medications, by Product Type?

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94 7 9 4 7

3838

50

24 2733

5359

43

75 7267

939490

0%

20%

40%

60%

80%

100%

HMO POS PPO HMO POS PPO HMO POS PPO

Tiers 1 or 2

Tier 3

Excluded

Revia Naltrexone Antabuse

Percent of Plans

What is the Coverage Pattern for Opiate Medications by Contracting Arrangements and Product Type?

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36

19

3946

6

57

63

5146

69

718

10 8

25

0%

20%

40%

60%

80%

100%

Specialty Internal HMO POS PPO

Tiers 1 or 2

Tier 3

Excluded

Suboxone

Percent of Plans

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