Medicaid provider says it plans to stop paying for drug that helps fight addiction

bmusgrave@herald-leader.comMay 10, 2012 

FRANKFORT — Medicaid provider Coventry Cares plans to stop paying for an expensive medication that helps addicts kick opioid addictions, a move state officials quickly condemned Thursday as a contract violation.

The Medicaid managed care company's decision to stop paying for buprenorphine, a drug used to curtail cravings for drugs such as Oxycontin and Vicodin, also brought the threat of a lawsuit from a group of addiction treatment centers. Buprenorphine is more commonly known as Suboxone.

Doctors who treat addiction said Coventry's decision could possibly lead to serious complications, relapse and even overdose deaths for recovering addicts.

"It's a cruel thing to do to people," said Dr. Michelle Lofwall, an addiction specialist and assistant professor at the University of Kentucky. "This is a population that is poor. It's not like they can afford to pay it out of pocket."

A 30-day supply of buprenorphine can cost more than $450.

Coventry, one of four companies hired by the state to manage Medicaid in Kentucky, told patients Wednesday that it would no longer pay for the medicine, although it does not intend to immediately cut coverage for recovering addicts already taking Suboxone.

Coventry said it is terminating coverage of buprenorphine because only pregnant women, women who recently gave birth and those under age 21 are eligible for addiction treatment in Kentucky's Medicaid program. It's not clear how many Coventry-covered patients receive the costly medication.

The Cabinet for Health and Family Services, which oversees the federal-state health insurance program for the poor and disabled, said late Thursday that it believes Coventry's decision violates its contract with the state.

"The cabinet believes that Coventry cannot take this unilateral action without the cabinet's approval and, in doing so, is in violation of its contract," said Jill Midkiff, a spokeswoman for the cabinet. "The cabinet will be sending a letter to Coventry to that effect. Coventry should continue to pay for Suboxone for its members who've been prescribed this medication."

Coventry's move also prompted an outcry from the Kentucky chapter of the American Society of Addiction Medicine.

"If someone were to suddenly not be able to have their medication, they would experience opiate withdrawal, which is very unpleasant," said Lofwall, who is vice president of the Kentucky Society of Addiction Medicine.

"They will be at risk for relapsing and going back to using illegal opioids," Lofwall said. "Whenever you are using illegal opioids, there is a risk of overdose and death."

Anna Whites, an attorney who represents SelfRefind, which operates several addiction treatment centers across Kentucky, said yanking the medication is akin to not covering a diabetic's insulin medication.

Whites said SelfRefind was poised to file a lawsuit in federal court on Friday, alleging that Coventry violated its contract with the state and federal law. But after learning of the state's decision to protest Coventry's move, Whites said SelfRefind will give the cabinet time to enforce the contract before filing a lawsuit.

"We are going to give them the chance to work this out," she said.

Whites said Coventry is supposed to provide the same type of coverage that Medicaid patients received before Nov. 1, when the state moved to managed care. Also, recovering addicts who are no longer using drugs are considered disabled under the Americans with Disabilities Act, she said.

Coventry counters that the cabinet never intended for Medicaid patients — except for youth and pregnant women — to receive the costly medication.

"Until very recently, Coventry has been covering substance abuse replacement therapy for all members," said Matt Eyles, a spokesman for Coventry. "What we've done is align our coverage with the cabinet's Medicaid policy."

Eyles said patients who have authorization for a prescription for several months will continue to receive Suboxone until the prescription expires. Patients whose authorization is set to expire can request an additional 15 days of the prescription, Eyles said.

But Whites said most physicians only give patients a one- or two-day supply of the drug so that it will not be abused. That means some patients could run out of the drug as early as this weekend.

Eyles also said Coventry notified the state of its decision in a March letter. But Midkiff said the cabinet told Coventry at the time that they could not stop paying for Suboxone. The cabinet will now reiterate that position in writing, Midkiff said.

Two other Medicaid managed care companies that began operating in the state last year — Kentucky Spirit and Well Care — have not given patients notice that they will discontinue payment for the drug, addiction specialists said Thursday.

"We need more drug treatment in Kentucky, not less," Lofwall said.

Coventry also has tried to sever its contract with Appalachian Regional Healthcare, which operates eight hospitals and other health clinics in Eastern Kentucky. After ARH sued Coventry in federal court, the two sides agreed to continue their existing contract until June 30.

Coventry also told King's Daughters Medical Center in Ashland that it would terminate its contract by the end of this month. Last week, Coventry told Baptist Healthcare System, which has hospitals in Lexington and Louisville, that it would like to renegotiate its contract with the system. That contract expires Nov. 1.

Coventry has said the state needs to adjust payments to the managed care providers because Coventry is covering a disproportionate number of high-risk patients. The state made such an adjustment in late April.

Beth Musgrave: (502) 875-3793. Twitter: @BGPolitics. Blog: bluegrasspolitics.bloginky.com

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