Health plans routinely require patients to obtain approval (called prior authorization) for prescribed care or medication as a way to control costs and oversee coverage decisions. This report, produced in collaboration with the Legal Action Center, analyzes state standards for prior authorization requirements for addiction treatment in both public and private insurance plans.

Background

Prior authorization requirements impose a unique barrier for individuals seeking substance use disorder (SUD) treatment. They delay the initiation of care at the critical moment when an individual needs treatment, placing patients at risk of continued substance use, medical complications, overdose and death.

Historically, health plans have required prior authorization for SUD services and medications more frequently than other medical services. The discriminatory use of prior and continuing authorizations is barred under the Mental Health Parity and Addiction Equity Act.

In response to the opioid epidemic, State lawmakers have stepped in to require system-wide removal of some prior authorization requirements. This report examines state statutory standards that limit the use of prior authorization in both public and private insurance. These standards supplement state regulatory actions that remove or restrict use of prior authorization requirements.

Key findings

• As of April 20, 2020, 21 states and the District of Columbia have enacted laws that limit public and/or private insurers from imposing prior authorization requirements on a SUD service or medication. Since 2019 alone, 15 jurisdictions enacted such laws.
• Seventeen (17) states have laws that limit state-regulated commercial plans from imposing prior authorization on SUD medications, and 13 states and the District of Columbia limit Medicaid from doing so.
• Ten (10) states limit state-regulated commercial plans from imposing prior authorization on SUD services, and 5 states limit Medicaid’s use of prior authorization for such services.

These state laws establish a patchwork of standards that do not protect all patients. Some regulate prior authorization for just opioid use disorder treatments, some remove prior authorization for “at least one” opioid use medication, others for all FDA-approved SUD medications. While research on the effect of removing prior authorization requirements for SUD medications and services is on-going, new research demonstrates that removing prior authorization for buprenorphine-naloxone increases the use of this medication and reduces hospitalizations and emergency department visits for SUD and other health conditions.

Recommendations

Absent strong regulatory or other action to ensure prompt access to SUD treatment, states should enact legislation to limit the use of prior authorization for all SUD services and FDA-approved formulations of SUD medications.