Description of Strategy
Prior authorization is a strategy used to minimize short-term costs of treatment for the insurer by requiring the provider to obtain insurer approval for certain services. Numerous state Medicaid programs require prior authorization for reimbursement of MAT, including documentation of the patient’s drug screening tests, or additional psychological counseling. To this point, “prior authorization is required for reimbursement of some form of buprenorphine and buprenorphine-naloxone in 40 and 31 of the 51 Medicaid programs, respectively, and extended-release injectable naltrexone requires prior authorization in 19 Medicaid programs” (SAMHSA, 2018, p. 50). However, prior authorization acts as a barrier to treatment for OUD, and its removal increases the likelihood that someone receives proper medical care.
Prior authorization of buprenorphine for MAT treatment in Wyoming is at the discretion of the insurance company. Blue Cross Blue Shield of Wyoming, the only insurer in the Wyoming health insurance exchange, does not require prior authorization for some forms of buprenorphine. Wyoming Medicaid has some prior authorization requirements.
Discussion of Effectiveness
While prior authorization can be used to oversee proper use of MAT-related drugs, it may ultimately serve as an obstacle to treatment, resulting in relapse (Burns et al., 2016). Likewise, these types of policies discourage many providers from prescribing opioids to patients that may need them (Beetham, 2019).
Beetham, T. (2019). Buprenorphine prior authorization removal: Low hanging fruit in the opioid epidemic fight. Harvard Public Health Review, 25(1), 1–5.
Burns, R. M., Pacula, R. L., Bauhoff, S., Gordon, A. J., Hendrikson, H., Leslie, D. L., & Stein, B. D. (2016). Policies related to opioid agonist therapy for opioid use disorders: The evolution of state policies from 2004 to 2013. Substance Abuse, 37(1), 63–69.
Substance Abuse and Mental Health Services Administration. (2018). Medicaid coverage of medication-assisted treatment for alcohol and opioid use disorders and of medication for the reversal of opioid overdose.