January 24, 2017

Anthem ends preauthorization requirement for medication-assisted substance use disorder treatment

Daily Briefing

    Anthem no longer will require preauthorization for coverage of medication-assisted treatment for opioid-related substance use disorders.

    Details of preauthorization rules change

    Anthem changed the policy as part of a settlement with the New York Attorney General's Office that has nationwide implications.

    Anthem previously required physicians to answer various questions about an individual's treatment and medication history before it would approve coverage for medication-assisted treatment. The New York Attorney General's Office conducted an investigation that found Empire BCBS in 2015 and the first half of 2016 denied about 8 percent of members' requests for medication-assisted treatment.

     In addition to the policy change, which affects Anthem plans nationwide, the settlement requires a New York-based Anthem-affiliated plan, called Empire BlueCross BlueShield (BCBS), to conduct provider outreach and education about the benefits of medication-assisted treatment.

    New York Attorney General Eric Schneiderman (D) last year a similar agreement with Cigna.

    Anthem announces opioid prescription reduction, treatment goals.

    In related news, Anthem on Wednesday announced that it will seek to:

    • Double the number of its members who receive behavioral counseling as part of medication-assisted treatment for opioid-related substance use disorders; and
    • Reduce opioid dispensation to its members by 30 percent from peak levels by the end of 2019.

    Internal research conducted by Anthem found between just 16 and 19 percent of its members who were prescribed medication-assisted treatment drugs also received in-person counseling. Such counseling is recommended as part of an individual's medication-assisted treatment plan.

    To address the issue, Anthem last year launched a pilot program in three of its affiliated health plans that implemented standardized medication-assisted treatment coding for physician and psychiatrists intended to maximize their reimbursements for providing such treatment and to ensure such reimbursements were consistent. Anthem said it also has worked to connect physicians with behavioral health support as a way to ensure the insurers' members can access counseling while receiving medication-assisted treatment. Anthem said it plans to launch those efforts in all of its affiliated health plans by early next year.

    Further, Anthem announced that all of its individual and employer- and government-sponsored health plans have been instituting limits on short- and long-acting opioid prescriptions in an effort to help curb opioid-related substance use disorders.

    Anthem Chief Clinical Officer Craig Samitt in a release said, "Untreated opioid use disorders put consumers at increased risk for experiencing a number of medical issues, including overdose, infectious diseases associated with intravenous drug use, and death." He added, "Making improvements with coordination and integration of medical and behavioral health care is an important factor to consider in efforts to mitigate these medical risks" (Haefner, Becker's Hospital Review, 1/20; O'Donnell/DeMio, USA Today, 1/19; New York Attorney General's Office release, 1/19; Anthem release, 1/18; Castellucci, Modern Healthcare, 1/20).

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