Insurers and PBMs Limit Access to Safer Opioid Alternatives

BIOtech Now
Andrew Segerman

Opioid abuse and addiction in America continues to ravish communities, families, and individuals across the nation. With an annual price tag exceeding $500 billion in health and social costs, solutions are needed to combat this growing problem before more damage is done.

Thankfully, the biopharmaceutical industry is hard at work developing novel and safer, next-generation therapies to treat both pain and addiction, but one challenge in particular continues to stand in the way: getting pharmacy benefit managers (PBMs) and insurers to pay for them.

By excluding what might be considered a safer medicine from a formulary – a list of permitted and excluded medications from an insurance plan – insurers and PBMs make patients pay the price.

This practice — highlighted recently in the Sun Journal — has become common as PBMs look for every excuse possible to keep their costs down.

“Rachel has been using an opioid pain control patch for several years to help her cope with the chronic pain of fibromyalgia. Her doctor prescribed the Butrans patch, which releases controlled doses of a milder, less addictive opioid known as buprenorphine.

“But after the 24-year-old woman moved from Massachusetts to Maine this year, a company called Express Scripts — which manages the pharmacy benefits for her Maine insurance company — refused to cover the Butrans patch.

“Express Scripts told Ostrom that her insurance would only cover patches using fentanyl or similar opioids — which are more addictive than buprenorphine and more likely to result in overdoses. If she wanted the Butrans patch — which is more expensive — she’d have to pay for it herself, at a cost of $800 a month.”

Rachel’s story is unfortunate but not unusual. In addition to restrictive utilization policies, insurance companies are also limiting the value of patient assistance programs provided by drug manufacturers.  And while Community Health Options (Ostrom’s insurance company) eventually agreed to continue covering the safer patch, the process was “frustrating and outrageous.”

We can achieve an addiction free America, but stakeholders from across the health care spectrum must be willing to do their part. BIO’s member companies are working to review and address coverage policies and practices that limit patient access to the safest, most appropriate form of treatment for an individual’s given condition it’s time for insurers and PBMs to make them available at prices patients can afford.

Read the full story in the Sun Journal here.

Full BIOtech Now Article here

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