September 19, 2018
Contact: Richard Loconte, 212-709-1691
DFS ANNOUNCES NEW ACTIONS TO COMBAT THE OPIOID CRISIS AND EASE ROADBLOCKS TO ADDICTION TREATMENT
Department of Financial Services Issues Final Regulation Requiring Insurers to Include Formulary Exception Process for Medication for the Detoxification or Maintenance Treatment of a Substance Use Disorder
DFS Also Issues Guidance Promoting Access to Less-Addictive Opioid and Non-Opioid Pain Medications and Reminds Insurers That Preauthorization Is Prohibited and Medical Necessity Review Is Restricted for In-Patient and Out-Patient Substance Use Disorder Treatment in State-Certified Facilities that Participate in the Insurer’s Provider Network
Financial Services Superintendent Maria T. Vullo today announced that the Department of Financial Services (DFS) is taking new bold actions to address the opioid crisis in New York State, ensuring that New Yorkers have swift access to appropriate addiction treatment, as well as access to less-addictive types of opioids and non-opioid pain medications. The measures announced today include a final DFS regulation that requires insurers to include in their policies a process for insureds, their designees or prescribers to request a review of a decision that a medication for detoxification or maintenance treatment of a substance use disorder drug is not covered by the policy. Today’s actions by DFS build on Governor Cuomo’s aggressive nation-leading efforts to break the cycle of heroin and opioid addiction and protect public health and safety.
“New Yorkers have the right to expect that their insurers won’t hinder access to the addiction treatments that are so vital to their recovery and that their health won’t be sacrificed in the pursuit of profits,” said Superintendent Maria T. Vullo. “DFS will monitor compliance with all substance abuse disorder treatment coverage requirements, including during market conduct exams, and take appropriate action against an issuer for any failure to adhere to all statutory and regulatory requirements, to protect the health of New Yorkers.”
Under the final regulation, every insurer that provides hospital, surgical, or medical expense coverage and also provides coverage for medication for the detoxification or maintenance treatment of a substance use disorder must include in the policy processes that allow an insured, the insured’s designee, or the insured’s prescribing physician to request a formulary exception and gain access to clinically appropriate medication for the detoxification or maintenance treatment of a substance use disorder not otherwise covered by the policy. Insurers must make determinations on standard exception requests and notify the insured, or the insured’s designee, and the insured’s prescriber no later than 72 hours after the request. Insurers must also have a process for expedited formulary exception requests based on exigent circumstances and make determination and notification no later than 24 hours after such requests.
To ensure that New Yorkers have access to less-addictive opioid and non-opioid pain medications, DFS has also issued guidance to inform insurers of their responsibilities surrounding the placement of opioid and non-opioid drugs prescribed for pain management in drug formulary tiers. DFS has received information that some insurers may be placing less-addictive types of opioids, such as buprenorphine, and non-opioid pain medications on their prescription drug formulary tiers based solely on the cost of the drug, reducing insureds’ access to these alternative pain medications. Formularies — lists of covered prescription generic and brand name drugs — can have a single tier in which all drugs have the same cost to the insured, or up to three tiers with varying costs.
Furthermore, DFS issued guidance today notifying insurers that tier placement of prescription drugs on a prescription drug formulary that includes varying levels of copayments or coinsurance for which a consumer is responsible may not be based on cost alone. Further, when reviewing the safety of either an opioid or non-opioid prescription drug used for pain management, the insurer should consider the addictive or non-addictive qualities of the prescription drug under review.
In addition, to ensure that individuals impacted by the opioid epidemic receive swift access to appropriate treatment, DFS advised insurers that, under New York Insurance Law, they are:
- Prohibited from requiring preauthorization for outpatient substance use disorder treatment in facilities that are certified by the New York State Office of Alcoholism and Substance Abuse Services (OASAS) and participate in the insurer’s provider network;
- Prohibited from performing concurrent utilization review, a process for determining coverage while a person receives treatment, during the first two weeks of continuous outpatient substance abuse disorder treatment in facilities that are certified by OASAS and participate in the insurer’s provider network provided the facility notifies the insurer of both the admission and the initial treatment plan within 48 hours of the start of treatment;
- Prohibited from requiring preauthorization for inpatient SUD treatment in facilities that are certified by OASAS and participate in the insurer’s provider network; and
- Prohibited from performing concurrent utilization review in facilities that are certified by OASAS and participate in the insurer’s provider network during the first 14 days of an inpatient admission provided the facility notifies the insurer of both the admission and the initial treatment plan within 48 hours of the admission.
These provisions apply to medication-assisted treatment performed as outpatient services at facilities that are certified by OASAS and participate in the insurer’s provider network.
In addition, the DFS guidance instructs insurers that, if they require preauthorization for substance use disorder treatment (other than in-network OASAS certified facilities, for which no preauthorization is permitted) more frequently than the insurer does for medical and surgical benefits in the same benefit classification, then the insurer must be prepared to demonstrate to DFS how it is in compliance with the Federal Mental Health Parity and Addiction Equity Act.
DFS also reminded insurers that every policy or contract that provides medical, major medical or similar comprehensive-type coverage and provides coverage for prescription drugs for the treatment of a substance use disorder must include immediate access, without preauthorization, to a five-day emergency supply of prescribed medications otherwise covered under the policy or contract for the treatment of a substance use disorder where an emergency condition exists, including a prescribed drug or medication associated with the management of opioid withdrawal or stabilization, except where otherwise prohibited by law. Coverage of an emergency supply includes medication for opioid overdose reversal otherwise covered under the policy or contract when prescribed to an individual covered under the policy or contract.
DFS encouraged insurers to refrain from performing preauthorization review on outpatient SUD treatment including prescription drugs so that individuals have immediate access to outpatient SUD treatment that is vital to their recovery.
New Yorkers struggling with an addiction, or whose loved ones are struggling, can find help and hope by calling the state's toll-free, 24-hour, 7-day-a-week HOPEline at 1-877-8-HOPENY (1-877-846-7369) or by texting HOPENY (Short Code 467369).
Available addiction treatment including crisis/detox, inpatient, community residence, or outpatient care can be found using the new and improved NYS OASAS Treatment Availability Dashboard at FindAddictionTreatment.ny.gov or through the Access Treatment page on the NYS OASAS website. Visit the #CombatAddiction website at oasas.ny.gov/CombatAddiction to learn more about how you can help to #CombatAddiction in your community.
Visit www.combatheroin.ny.gov for more information on addressing heroin and prescription opioid abuse, including a Kitchen Table Tool Kit to help start the conversation about the warning signs of addiction and where to get help. For tools to use in talking to a young person about preventing alcohol or drug use, visit the State's Talk2Prevent website.
A copy of the final regulation can be found here.
A copy of the circular letter related to tier placement of less-addictive opioid and non-opioid medications can be found here.
A copy of the circular letter related to preauthorization and utilization review for substance use disorder treatment can be found here.