Too Often, Insurers Cover Opioids But Not Addiction Treatment Meds

By Kelly Burch 07/06/18

“Buprenorphine and methadone are incredibly effective medications... So I really do think it’s a stigma issue.”

doctor describing medication to patient

As is the case for many people battling opioid addiction, Mandy’s dependency started at home. She was prescribed an opioid for back pain, and her insurance company gladly covered the cost of the pills.

However, after Mandy became dependent on opioids and was prescribed buprenorphine to help with her rehabilitation program, her insurer stepped back, unwilling to pay.

“It makes me want to go out and use [drugs],” Mandy said when she spoke to Vox. The 29-year-old who lives in the Chicago area asked that only her first name be used. “It’s way easier to get opiates or heroin… It’s so much easier than dealing with this bullshit.” 

Many Americans who had no problem getting their insurance companies to pay for addictive opioid pain pills have found that getting insurers to cover treatment—particularly medication-assisted treatment (MAT) that relies on pharmaceuticals like buprenorphine—is an uphill battle despite the fact that the drugs have been proven effective. 

“Buprenorphine and methadone are incredibly effective medications,” said Tami Mark, a health economist at RTI International, a non-profit that conducts policy research. “If you had any other drug with their kind of effect size, it would be immediately covered… So I really do think it’s a stigma issue.”

For people in early recovery, like Mandy, refusals to cover medications or delays in getting prescriptions approved can be deadly.

“The risk of relapse is incredibly high,” said Sara Ballare-Jones, a social work case manager at the University of Kansas Health System. She often has patients wait three days to get their medications approved because they require prior authorization from the insurance companies.

In Mandy’s case her claim was denied, leaving her to pay out of pocket for buprenorphine, which costs nearly $3,000 each year. The 29-year-old said that is a huge amount to have to pay while also handling daily expenses like student loans and rent.

“I’m feeling all these old issues and all this shit, and then it’s just more bullshit,” she said. “I’m just trying to reenter society… It’s really hard.”

It’s also incredibly frustrating for Mandy, who knows firsthand how easy it is to get insurers to cover opioids. “I never paid a dime for my opioids. Those were always covered,” she said. “But I’m paying all this money for the treatment.”

Mandy’s doctor, Dennis Brightwell, said that he usually sees issues with private insurance companies. While Medicaid is required to cover most medication-assisted treatments, most private insurers balk at covering them, putting vulnerable patients in an awkward position.

“If you send a commercial patient to the pharmacy, you don’t know until they get there how it’s going to go,” Brightwell said. “Sometimes it’s not such a problem. Sometimes it’s a prior authorization that is pretty straightforward. Sometimes it’s very difficult to get them to approve it. And there’s not an easy way to find out upfront what medications they approve.” 

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Kelly Burch writes about addiction and mental health issues, particularly as they affect families. Follow her on TwitterFacebook, and LinkedIn.