A.G. Schneiderman Announces National Settlement With Anthem To Discontinue Pre-Authorization For Opioid Addiction Treatment Drugs

News from Attorney General Eric T. Schneiderman

January 19, 2017

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Following Agreement With Cigna, Anthem Is Second Settlement Attorney General Schneiderman Has Reached To Remove Barriers and Expand Access To Life-Saving Treatment For Opioid Use Disorder

Empire BlueCross BlueShield Will Also Launch Initiative In New York To Expand Access To Opioid Addiction Treatment Drugs

NEW YORK – Attorney General Eric T. Schneiderman today announced that Anthem, the second largest health insurer in the country, will end its policy of requiring prior authorization for medication-assisted treatment (“MAT”) for opioid use disorder. The agreement includes Empire BlueCross BlueShield (BCBS), which insures over 4 million New Yorkers, and resolves Attorney General Schneiderman’s investigation of prior authorization practices and network adequacy for MAT treatment. The agreement comes several months after Attorney General Schneiderman announced a similar agreement with Cigna.

MAT, when prescribed and monitored properly, has proved effective in helping patients recover from opioid use disorder, and is both safe and cost-effective to reduce the risk of overdose. This policy change will apply not only to most Anthem members in New York, but nationally as well. 

“We’re facing an opioid crisis in New York and around the country – and we should be doing whatever we can to make lifesaving treatments accessible to those suffering from addiction,” said Attorney General Schneiderman. “I am pleased that this is the second national settlement my office has reached with major insurers to remove hurdles to opioid addiction treatment. While we’ve made progress, there are too many still suffering. We’re committed to continue working with health insurers across the country to eliminate barriers to lifesaving opioid addiction treatments.”

Anthem required providers to submit a prior approval form for MAT coverage requests, which required the providers -- who had already received specific training regarding MAT and federal authorization to prescribe these drugs -- to answer numerous questions about the patient’s current treatment and medication history. The Attorney General’s investigation revealed that Empire BCBS denied nearly 8% of the overall requests for coverage of MAT in 2015 and the first half of 2016. This subsequently caused significant delays in patients obtaining treatment for addiction – or patients never obtaining the treatment at all.

In contrast to its policy for drugs to treat opioid use disorder, Empire BCBS does not require prior authorization for the majority of drugs it covers for medical conditions. In particular, Empire BCBS does not require prior authorization for powerful opioids, including fentanyl, morphine, tramadol, and oxycodone, when prescribed for pain. These disparities are not consistent with the New York and federal mental health parity laws, which require health plans to cover mental health and substance use disorder treatment the same way they cover treatment for physical conditions.

Under the agreement, Empire BCBS will also launch an initiative to expand access to MAT for members in its New York service area. Empire BCBS will conduct provider outreach and education regarding the benefits of MAT, informing qualified health care providers how they can obtain certification from the Substance Abuse and Mental Health Services Administration (“SAMHSA”) to prescribe buprenorphine and buprenorphine/naloxone as part of MAT for opioid dependence. Empire BCBS will provide the Attorney General with a list of MAT providers who have joined its network as a result of this initiative.

Unlike methadone treatment, which must be administered in a highly structured clinic, MAT medications, usually containing buprenorphine and naloxone, may be prescribed or dispensed in physicians’ offices to treat opioid use disorder, provided the treating physician has obtained the appropriate certification and has been issued a special DEA license. In addition to the medication component, psychosocial therapy and management of medical issues are also recommended components of MAT to treat opioid use disorder.

Buprenorphine is an opioid partial agonist, meaning that it has lesser euphoric effects than full opioid agonists such as heroin. At low doses, buprenorphine produces sufficient agonist effects to enable opioid-addicted individuals to discontinue the misuse of opioids without experiencing withdrawal symptoms. Buprenorphine carries a lower risk of abuse, addiction, and side effects when compared with full opioid agonists. Naloxone is an opioid antagonist that can be added to buprenorphine that will decrease the likelihood of diversion and misuse of the combination drug product. If the combination drug product is crushed and injected the naloxone and can bring on opioid withdrawal, which serves as a deterrent to diversion and misuse.

The Centers for Disease Control and Prevention considers MAT a proven, effective treatment for individuals with an opioid use disorder. MAT has been shown to increase treatment retention and to reduce opioid use. One study showed that for half the patients treated with buprenorphine/naloxone for addiction to prescription opioids, they were abstinent from the drugs 18 months after starting MAT, and after three and a half years, 61% of the patients reported abstinence from illicit opioids. MAT is supported and endorsed by the CDC, the Substance Abuse and Mental Health Services Administration (SAMHSA), the American Society of Addiction Medicine (ASAM), the New York State Office of Alcoholism and Substance Abuse Services (OASAS) and the New York City Department of Health and Mental Hygiene (NYCDOHMH) as a treatment for opioid addiction.

In a recently issued report, the Centers for Disease Control (CDC) reports that more than 33,000 people nationally died from opioid overdoses. In New York in 2015, there were almost 2,800 overdose deaths, with overdose deaths from synthetic opioids (such as fentanyl) increasing by 135% from 2014, and heroin overdose deaths increasing by 29% from 2014.

Addressing access barriers to MAT is just the latest step that Attorney General Eric T. Schneiderman has taken to address the opioid addiction crisis. In June of 2011, Attorney General Schneiderman introduced state legislation for I-STOP, an online Prescription Monitoring Program or a “PMP,” that enables doctors and pharmacists to report and track controlled narcotics in real time. I-STOP became effective in August of 2013, making New York State one of the first states to establish such a PMP, and has reduced “doctor-shopping” by 75%. The OAG has also aggressively enforced laws that require parity in health plan coverage of mental health and addiction treatment, reaching agreements with six companies, including Anthem, MVP Healthcare, EmblemHealth, Excellus, Beacon Health Options, and HealthNow. Most recently, in October 2016, the Attorney General announced a national agreement with Cigna, which agreed to remove prior authorization requirements for MAT. The Attorney General’s Office has prosecuted many individuals who have engaged in the illegal distribution and sale of narcotics as well as health care providers who illegally prescribed and diverted opioids. The OAG’s Community Overdose Prevention (COP) Program, which equips New York law enforcement agencies with a life-saving heroin overdose antidote, has saved more than 100 lives. The OAG has also reached agreements with Purdue Pharma and Endo Pharmaceuticals Inc., to ensure that these opioid makers engage in responsible and legal marketing. 

Anthem’s policy change follows efforts by both New York State and the federal government to increase access to MAT for opioid use disorder. New York State recently enacted legislation prohibiting insurers from requiring prior authorization for emergency supplies of MAT medications and also removed prior authorization for Medicaid members seeking MAT for opioid use disorder, while the federal government increased the maximum number of patients that MAT-certified providers can treat at one time from 100 to 275 and now permits qualified nurse practitioners and physician assistants to prescribe MAT drugs.

“ASAM welcomes Attorney General Schneiderman’s agreement with Anthem to discontinue the requirement of prior authorization requirements to cover buprenorphine containing medications.  We also applaud the agreement for Empire BCBS to actively work to improve access to effective opioid treatment with MAT for their network members and to provide evidence for that improved access. We hope to see other payers following the lead of Cigna and Anthem on this critical issue,” said Kelly J. Clark, President Elect of the American Society of Addiction Medicine.

“We applaud Attorney General Schneiderman for continuing to challenge discriminatory barriers to drug treatment.  Preauthorization requirements for addiction medication are not only discriminatory, but cost lives.  It is critical that all health insurers offer the full range of medications to treat substance use disorders, without imposing illegal barriers to these life-saving treatments,” said Sally Friedman, Legal Director, Legal Action Center.

“My son, Michael, was denied treatment he desperately needed,” said Avi Israel, President and Founder of Save the Michaels of the World. “This settlement removes the prior authorization obstacle for MAT that too many families have faced for too long. I thank Attorney General Schneiderman for his hard work.”

“Many individuals with mental illness also have a co-occurring addiction disorder. A significant impediment to getting medication—assisted treatment (MAT) for opioid use disorder in the pre authorization challenges that many individuals face. We applaud Attorney General Schneiderman and his staff for advocating strongly for individuals with behavioral health needs, by both working to highlight and eliminate these pre-authorization practices,” said Glenn Liebman, CEO, Mental Health Association in New York State.

Richard D. Blondell, MD, Professor and Vice Chair for Addiction Medicine in the Department of Family Medicine, University at Buffalo said, “this practice created a huge burden on the staff of medical offices and was associated with a delay in the treatment of patients. When a person who has an opioid use disorder decides to seek help, there is typically a small window of opportunity to engage that individual in effective treatment; waiting for days to treat this condition represents an unnecessary risk that can be deadly for some.”

Kevin Jones, the Executive Director of the Heroin Epidemic Action League (HEAL) of Auburn said, “this agreement with the Attorney General is a great step forward in the battle against opioid abuse. When an addict finally reaches the point where they are ready to do something about their problem, there is only a short window of time to get them treatment. Without immediate medical assistance, many return back to the streets, and it may never cross their mind again to seek help. People die every day from using drugs, while waiting for help. That was the case with my step daughter. This agreement will save thousands of lives.

“The Long Island Council on Alcoholism and Drug Dependence (LICADD) wishes to convey our debt of gratitude to NYS Attorney General Eric Schneiderman who continues to advocate for the rights of substance users to access evidence-based treatment modalities void of stigma and inequities often displayed in the excluding policies of insurance companies. In times of great crisis, there emerges individuals with a great sense of duty and responsibility. AG Schneiderman has demonstrated his willingness to engage in effective action in challenging these inequities demonstrated by insurance companies to insure all New Yorkers, and their families, afflicted with the disease of substance use disorders have equal access to the quality care and treatment afforded to individuals living with other diseases and conditions.  On behalf of the thousands of individuals and families we serve at LICADD, thank you Mr. Attorney General,” said Steve Chassman, LCSW, CASAC- LICADD Executive Director.

“Medication-assisted treatment can provide a path to recovery for those struggling with addiction,” said Jennifer Faringer, M.S.Ed., CPP, Director of the National Council on Alcoholism and Drug Dependence-Rochester Area (NCADD-RA). “The Monroe County Opioid Task Force is focused on eliminating barriers to treatment, and Attorney General Schneiderman’s continued push to end prior authorizations for MAT is crucial to this effort.”

Consumers with questions or concerns about this settlement or other health care matters may call the Attorney General’s Health Care Bureau Helpline at 1-800-428-9071.

Read the agreement with Anthem.

The investigation of this matter was conducted by Assistant Attorneys General Brant Campbell and Michael D. Reisman, of the Attorney General’s Health Care Bureau, which is led by Bureau Chief Lisa Landau. The Health Care Bureau is a part of the Social Justice Division, led by Executive Deputy Attorney General for Social Justice Alvin Bragg.