Coverage and Management of Medications for Treating Substance Abuse in Health Plans

1. 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)

2. 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

3. 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

4. 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 Institutefor Behavioral Health

5. 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 Research Domains Institute for Behavioral Health

6. 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

7. 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

8. What is the Pattern of Exclusion and 3-Tier Usage for SA Medications? Revia Naltrexone Antabuse Suboxone Percent of Plans Institute for Behavioral Health

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

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

11. What is the Coverage Pattern for Alcohol Medications, by Contracting Arrangements? Revia Naltrexone Antabuse Percent of Plans Institute for Behavioral Health

12. What is the Coverage Pattern for Alcohol Medications, by Product Type? Revia Naltrexone Antabuse Percent of Plans Institute for Behavioral Health

13. What is the Coverage Pattern for Opiate Medications by Contracting Arrangements and Product Type? Suboxone Percent of Plans Institute for Behavioral Health

14. 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

15. 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