Buprenorphine Remains Underutilized Despite Relaxed Regulations

In 2021, almost all commercial, Medicare Advantage and Medicaid health plans covered at least one immediate-release buprenorphine, a medication for treating opioid use disorder (OUD), according to a recent Health Affairs study. Also, since 2017, fewer health plans have been requiring prior authorization and quantity limits for those medications.

However, fewer than half of commercial formularies and one-fifth of MA formularies covered extended-release buprenorphine products in 2021. Comparatively, 82.8% of Medicaid formularies covered such medications, and the share of Medicaid formularies without prior authorization requirements increased from 6.8% in 2018 to 63.3% in 2021.

On May 23, 2023, the FDA approved Brixadi (buprenorphine) extended-release injection as a new option to treat moderate to severe OUD, joining an array of available treatment alternatives such as Sublocade (buprenorphine extended-release), Suboxone (buprenorphine and naloxone) sublingual film and Zubsolv (buprenorphine and naloxone) sublingual tablet. Under the pharmacy benefit, the majority of CVS Caremark and Express Scripts commercial-formulary enrollees have coverage for Sublocade and Zubsolv with no prior authorization requirements, according to the latest coverage policy analysis from MMIT Analytics (MMIT is the parent company of AIS Health). Meanwhile, coverage of Suboxone across all three major PBMs and their payer units is limited.

Meanwhile, patients may encounter barriers when filling buprenorphine products at local pharmacies, according to a recent study published in JAMA Network Open. The researchers analyzed over 5,000 unique pharmacy calls representing 3,779 patients between Jan. 1 and Dec. 31, 2022, and found that only 57.9% of pharmacies reported buprenorphine products in stock at the time of request. Chain pharmacies were more likely to have the medications in stock than independent pharmacies. The availability rates also varied significantly by state, ranging from 37.1% in Florida to 83.9% in Washington.

Nearly 110,000 people died of drug overdoses in 2022, slightly higher than the number in 2021, according to the Centers for Disease Control and Prevention. As one of the gold standards for OUD treatment, buprenorphine has been widely used as a medication-assisted treatment (MAT). The Comprehensive Addiction and Recovery Act of 2016 allowed nurse practitioners and physician assistants to seek a federal waiver to prescribe buprenorphine for OUD, and over 50,000 practitioners are currently authorized across the nation. AIS Health’s analysis found that Tennessee, Louisiana, South Carolina and Missouri had significantly lower rates of buprenorphine practitioners per opioid overdose death, suggesting a shortage of buprenorphine prescribers in those states.

At the start of the COVID-19 pandemic, buprenorphine prescribing regulations were relaxed to allow patients to receive prescriptions through telemedicine. In addition, practitioners were no longer required to undertake an eight-hour federal educational program to be eligible to prescribe buprenorphine starting in 2021. Yet a recent research letter published in JAMA Network suggested that buprenorphine initiation trends remained flat between 2018 and 2022. Only 22% of those who started a course of buprenorphine kept refilling their prescriptions for at least six months from 2016 through 2022.

This infographic was reprinted from AIS Health’s biweekly publication RADAR on Drug Benefits.