Most Virginians don’t spend a lot of time thinking about how Medicaid decides which medications to cover. Neither did I, until it started mattering to folks I know. A person whose doctor wanted to try a non-opioid medication after surgery – exactly the kind of acute pain situation these drugs are approved for (the safer option) – was required to fight through the coverage system.
An opioid would not have been difficult.
About the author
- Keisha Wright is founder of ProActive Behavioral Services, a Henrico-based community advocacy organization with locations also in Richmond and Petersburg.
Currently, before a patient can receive coverage for certain non-opioid pain medications, the state can require them to first try two other drugs and show that both failed – step therapy. There may be prior authorization requirements layered on top of that as well. The process can take weeks, during which someone is managing pain without the treatment their doctor wanted.
An opioid prescription moves through without any of those requirements. No failure, no waiting, just coverage.
Virginia is among the most restrictive in the country when it comes to coverage barriers on non-opioid pain medications, and among the most permissive when it comes to opioids. I do not think most Virginians know that. But once you know it, it is hard to look away – because we have spent years as a Commonwealth mourning what opioids have done to our communities. The idea that our own coverage rules are quietly tilting people toward opioids rather than away is something we shouldn’t have to accept.
The numbers add weight to what I have seen up close. Virginia recorded nearly 2.8 million Medicaid opioid prescription claims in 2021 alone – one of the highest rates in the country. At the same time, the FDA has approved a growing number of non-opioid drugs for the treatment of pain – options that work for serious pain situations, that carry no addiction risk, and that physicians want to use.
The barrier isn’t due to science. It is administrative. And it is one Virginia has the authority to remove.
There is a straightforward fix on the table right now. There is a budget amendment that would direct Virginia’s Medicaid drug coverage committee to ensure that no FDA-approved non-opioid pain treatment faces more restrictive coverage than an opioid. It simply says the non-opioid should not be harder to access than the opioid. That’s it.
This amendment removes a disadvantage that has no good justification – a coverage gap that exists not because anyone decided non-opioids should be harder to get, but because the system was never corrected to reflect what we now know.
The conference committee in Richmond is finalizing the budget now. Budget negotiators should include this amendment – not as a health policy, but as a statement about what Virginia believes.
We believe people in pain deserve a fair shot at a treatment that will not put them at risk of addiction.
The moment to fix this, when the fix could be a simple line in the budget, is now.
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