Insurer Hopes Payment Change Spurs More Addiction Treatment

Cigna Behavioral Health (CBH), a nationwide managed care organization and subsidiary of Cigna Corp., has begun to reimburse physicians for office-based buprenorphine induction treatment at a higher rate than for regular office visits.

Sublingual buprenorphine is one of the few pharmacological treatments approved by the Food and Drug Administration for treating individuals with opioid dependence. It is a Schedule III narcotic and the only medication approved to treat opioid dependence at physician offices under the Drug Addiction Treatment Act of 2000.

The induction phase of buprenorphine treatment costs more than a routine office visit, because it requires close supervision of the patient at the physician's office as the patient undergoes opioid withdrawal. The induction phase may involve several visits and intense monitoring, according to guidelines in the approved prescribing information provided by the Center for Substance Abuse Treatment (CSAT). Physicians must titrate the dose of buprenorphine until the patient can be put safely on an effective maintenance dose.

To prescribe buprenorphine for outpatient treatment, physicians must first receive training and certification and register with CSAT. Compared with methadone (a Schedule II narcotic), buprenorphine gives patients a favorable alternative because the induction visits are conducted at a physician's office, as opposed to designated clinics, and the maintenance therapy can be achieved in the privacy of patients' homes.

In May CBH announced that it had adopted the new physician-reimbursement policy to improve its members' access to the treatment and to encourage more physicians in its network to initiate buprenorphine treatment.

In an interview with Psychiatric News, Doug Nemecek, M.D., national medical director at CBH, explained that the program was implemented after providers told CBH that some patients had to pay out of pocket for buprenorphine induction because the reimbursement rate for these visits was too low, and managed care plans have no mechanism for determining compensation for the complex and sometimes lengthy visits.

“Improving the coverage for buprenorphine use in the treatment of opioid dependence is a welcome step forward,” Eric Strain, M.D., a professor at the Department of Psychiatry and Behavioral Sciences at Johns Hopkins University School of Medicine and chair of APA's Council on AddictionPsychiatry, commented to Psychiatric News. “I am very pleased to hear that Cigna intends to increase the availability of buprenorphine for patients, given the effectiveness of treatment for opioid dependence.”

Earlier this year, Cigna instructed its network physicians who are authorized to prescribe buprenorphine to bill induction visits using CPT code H0033. Three sessions are initially authorized with additional induction visits covered upon clinical review.

Buprenorphine is a partial agonist of the mu-opioid receptor and an antagonist of the kappa-opioid receptor. Used alone or in combination with naltrexone, sublingual tablet formulations of buprenorphine (Subutex and Suboxone) are approved for medication-assisted treatment for opioid dependence. CSAT stated that buprenorphine has “maximal effects less than those of full agonists like heroin and methadone” and“ carries a lower risk of abuse, addiction, and side effects compared to full opioid agonists.” Because of the partial agonist property, buprenorphine also produces less severe withdrawal symptoms than full opioid agonists.

Additional information on buprenorphine for treatment of opioid dependence is posted at<http://buprenorphine.samhsa.gov>.▪