Harrisburg, PA – The Wolf Administration today announced a major agreement with commercial insurers in Pennsylvania to align prior-authorization processes for opioid prescriptions to protect patient health and safety while ensuring patients have unrestricted access to medication-assisted treatment (MAT) when needed to battle opioid addiction.
“It is vital we take all possible steps to make sure patients are receiving the most appropriate treatment for their pain, while at the same time appropriately managing and monitoring the risks associated with opioids,” Department of Health Secretary Dr. Rachel Levine said. “Medication-assisted treatment is an effective, evidence-based treatment to help those with the disease of addiction to opioids and this step by private insurers allows more people with opioid use disorder to be able to access this form of treatment. Treatment works, and recovery is possible for those who are battling this disease.”
“I want to thank Governor Wolf for his continued leadership on battling the opioid crisis in our state, and our insurers for coming to the table to find ways to cover appropriate treatment when it is needed, and for working with our medical providers to properly manage and monitor this treatment,” Insurance Commissioner Jessica Altman said.
Today’s action follows a summit last fall among Pennsylvania’s largest health insurers serving both the state’s commercial insurance markets and the Medicaid managed care program, the departments of Drug and Alcohol Programs, Health, and Human Services, and the Insurance Department. The summit was part of the administration’s ongoing effort to battle the opioid crisis.
Today’s announcement closely aligns commercial insurance prior-authorization requirements for opioid prescriptions and access to MAT with those now used by both Medicaid fee-for-service and managed care programs, which were implemented earlier this year by the Department of Human Services. Commercial insurers agreeing to these guidelines are Aetna, Capital BlueCross, Geisinger, Highmark, Independence Blue Cross, UPMC, and UnitedHealthcare.
“As we fight the opioid crisis, our focus should be on removing barriers to treatment wherever they may exist and helping people battling addiction get the treatment they need,” said Department of Human Services Secretary Teresa Miller. “When someone decides they are ready for treatment, time is critical. Time spent waiting for a service authorization makes it more difficult for the individual who initiates treatment to remain engaged in treatment.”
These guidelines apply to individual, small group, and large group fully insured plans. Self-funded plans, where employers provide health care coverage administered by a third party, are regulated by the federal government and are not included in this agreement.
The guidelines implement thresholds for prior authorization for long- and short-acting opioids, morphine milligram equivalents (MME) and exceptions for active cancer, sickle cell crisis, and palliative care/hospice patients. Generally, commercial insurers are requiring prior authorization for all long-acting opioid prescriptions and short-acting opioid prescriptions after seven days. Some insurers are phasing in their alignment with many of the guidelines. Patients should consult with their insurer to find out how these guidelines are being incorporated into their specific health plan.
Providing unrestricted access to all commonly used forms of MAT when patients need it is critical to ensuring any individual struggling with addiction can access the type of treatment that is best for them. Under this agreement, commercial insurers will cover MAT without prior authorization in the following ways:
- Coverage of at least one Buprenorphine/naloxone combination product
- Coverage of Methadone as MAT
- Coverage of injectable and oral Naltrexone
Commercial insurers have also committed to coverage of at least one form of nasal naloxone without quantity limits.
“These changes are a key component to ensuring individuals receive the necessary care to start their journey into recovery,” said DDAP Secretary Jen Smith. “Now physicians can immediately begin a treatment regimen, alleviating a time-sensitive obstacle for the individual in need. The guidelines, paired with our warm hand-off protocols, are critical components to easing access of treatment for Pennsylvanians.”
The guidelines also provide that MAT will be covered at the lowest patient cost tier on the plan’s pharmacy benefit, as applicable.
Standard opioid prior authorization guidelines to determine medical necessity are consistent with Centers for Disease Control and Pennsylvania Department of Health guidelines on the use of opioids to treat chronic non-cancer pain. Opioid prescribing guidelines can be found here.
Individuals seeking recovery resources for themselves or a loved one can call the toll-free PA Get Help Now helpline at 1-800-662-HELP (4357). A live chat option is also available online or via text message at 717-216-0905 for those seeking help who may not be comfortable speaking to a helpline operator.
Find more information on the state’s efforts to battle the opioid crisis here.
MEDIA CONTACT: Elizabeth Rementer, PID – 717-787-3289
Colin Day, DHS – 717-425-7606
Nate Wardle, Health, 717.787.1783
Rachel Kostelac, DDAP, 717.547.3314