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 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 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** Institute for Behavioral Health * 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? Institute for Behavioral Health ReviaNaltrexoneAntabuseSuboxone Percent of Plans

How Often is Tier 3 Used for SA Medications? **if medication is covered Institute for Behavioral Health Percent of Plans with Medication on Tier 3 AlcoholOpiate

How Often is Prior Authorization Required for SA Medications? **if medication is covered Insitute for Behavioral Health Percent of Plans Requiring Prior Authorization AlcoholOpiate

What is the Coverage Pattern for Alcohol Medications, by Contracting Arrangements? Institute for Behavioral Health ReviaNaltrexoneAntabuse Percent of Plans

What is the Coverage Pattern for Alcohol Medications, by Product Type? Institute for Behavioral Health ReviaNaltrexoneAntabuse Percent of Plans

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