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Insurance Coverage of Buprenorphine Varies Widely By Formulation
Although most insurance plans cover the sublingual formulation of buprenorphine, a new study released by the University of Central Florida finds that less than half of commercial plans cover extended-release buprenorphine injections. Moreover, while most Medicaid plans cover the extended-release, injectable formulation, more than a third require prior authorization before a prescription.
Findings were published in the journal Health Affairs.
Researchers from UCF and 4 other universities reviewed Medicaid, Medicare Advantage, and commercial insurance formulary files to compare the plans’ respective restrictions regarding the medication used to treat opioid addiction from 2017 to 2021. Insurance coverage, prior authorization requirements, and other access barriers, such as step therapy and quantitative limits across plans were analyzed.
The researchers found significant differences in coverage and prior authorization requirements depending on the buprenorphine formulation sought by plan members. Nearly all plans reviewed covered at least 1 form of immediate-release buprenorphine in 2021, with prior authorization requirements and quantity limits generally decreasing over the period studied, according to a UCF news release.
Just 46% of commercial plans and 19% of Medicare Advantage plans covered extended-release injectable buprenorphine, however. Most Medicaid plans covered the extended-release formulation in 2021, but 37% required prior authorization.
“The reason prior-authorization requirements are a problem is that someone with an addiction may have a short window of time during which they're willing to go and get treatment,” study lead author Barbara “Basia” Andraka-Christou, associate professor, UCF School of Global Health Management and Informatics, said in the news release.
“From a public health standpoint, it’s very important to not have prior-authorization requirements for these types of medicines. The injection is also very expensive because it's still on patent, so those requirements probably exist to cut costs. However, if someone had to wait days for the injection and has an overdose in that timeframe, then it might be less costly to not require prior authorization.”
Buprenorphine Dispensing Still Increasing Overall
Despite the limitations on insurance coverage for the extended-release, injectable formulation of buprenorphine, a separate analysis by Kaiser Family Foundation (KFF) found a 24% increase in overall dispensing of the medication from 2019 to 2022. KFF’s research did not specify dispensing rates for specific buprenorphine formulations in its report.
KFF noted that access to care was increased by a pandemic-related policy change that allowed the initiation of buprenorphine treatment via telehealth, without an in-person visit. Furthermore, federal legislation enacted in late 2022 removed the X-waiver requirement for buprenorphine prescribing, increasing the potential number of authorized prescribers. However, KFF said its research shows many practitioners still may not prescribe buprenorphine and disparities in access to treatment may remain.
Lastly, KFF reported that as of June, 14 states have submitted Section 1115 waivers seeking an exemption from federal laws that prohibit the use of Medicaid funding for healthcare services for incarcerated individuals, including opioid use disorder treatment. Past studies have found that nearly two-thirds of those incarcerated have a substance use disorder, and they face a risk of overdose upon release that is 10 times higher than that of the general population, KFF said.
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