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Many Insurance Plans Cover Opioid Painkillers But Restrict Access To Less-Addictive Drugs

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With an opioid addiction epidemic ravaging the nation, physicians are being asked to consider non-opioid treatments or opioids that are less addictive than the widely abused drugs on the market. But there’s a big problem with that suggestion: Many insurance companies won’t cover, or heavily restrict access to, a number of less-addictive painkillers.

According to a new joint report from ProPublica and the NY Times, a large number of insurance plans make it difficult or expensive for patients to acquire effective treatments that aren’t highly addictive opioids like oxycodone and morphine.

We’re not talking about insurance plans failing to cover unproven homeopathic remedies or herbal treatments. This is about insurers limiting patients’ ability to obtain proven non-opioid drugs like lidocaine or Lyrica (pregabalin).

In some cases, the insurance companies won’t cover a drug at all, or only covered if the patient receives prior approval from the insurer. In other situations, the non-opioid drug is placed on a pricing tier by the insurance company that the patient can’t afford it or requiring that the patient try other, less-expensive drugs first.

One 33-year-old patient tells ProPublica that she’d successfully made the switch from opioids to Lyrica to treat her chronic pain. But when she switched jobs — and insurance plans — her new insurer, Anthem, refused to pay for the patient’s Lyrica prescription because it believes there is not enough evidence to show that the drug actually works on her particular condition. Anthem says patients in this situation can apply for an exception; the patient says her application was turned down by the insurer.

She can’t afford to pay the $520/month retail price for Lyrica, so what are her options? The least expensive would be to go back on opioid painkillers, which are generally on insurance companies’ lowest price tiers. Instead, she chose a compromise, switching to anti-seizure medication gabapentin, which is less expensive than Lyrica, but which the patient says is not effective. Though she’s avoided doing so, she says she can see why some patients in her same situation would choose to just go back to the more effective, less-expensive, but highly addictive opioids.

Insurance companies are also limiting access to less-addictive opioid painkillers. ProPublica talked to a 28-year-old woman with chronic abdominal pain. She had been able to manage her ailment with Butrans, a patch containing the drug buprenorphine, which is an opioid but which is generally considered less dangerous and addictive than morphine. But it’s also more expensive.

Earlier this year, the woman’s insurance company, United HealthCare, decided it would no longer cover these patches. United’s solution? Morphine, which it approved without any issues.

“Because my Butrans was denied, I have had to jump into addictive drugs,” says the patient, who has asked her husband to help make sure she doesn’t slip into addiction.

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