Variation in Initiation, Engagement, and Retention on Medications for Opioid Use Disorder Based on Health Insurance Plan Design

BACKGROUND: The association between cost-sharing and receipt of medication for opioid use disorder (MOUD) is unknown. METHODS: We constructed a cohort of 10,513 commercially insured individuals with a new diagnosis of opioid use disorder (OUD) and information on insurance cost-sharing in a large national de-identified claims database. We examined four cost-sharing measures: 1) pharmacy deductible; 2) medical service deductible; 3) pharmacy medication co-pay; and 4) medical office co-pay. We measured MOUD (naltrexone, buprenorphine, or methadone) initiation (within 14 days of diagnosis), engagement (second receipt within 34 days of first), and 6-month retention (continuous receipt without 14-day gap). We used multivariable logistic regression to assess the association between cost-sharing and MOUD initiation, engagement, and retention. We calculated total out-of-pocket costs in the 30 days following MOUD initiation for each type of MOUD. RESULTS: Of 10,513 individuals with incident OUD, 1,202 (11%) initiated MOUD, 742 (7%) engaged, and 253 (2%) were retained in MOUD at six months. A high ($1,000+) medical deductible was associated with a lower odds of initiation compared to no deductible (odds ratio: 0.85, 95% CI: 0.74-0.98). We found no significant associations between other cost-sharing measures for initiation, engagement, or retention. Median initial 30-day out-of-pocket costs ranged from $100 for methadone to $710 for extended-release naltrexone. CONCLUSION: Among insurance plan cost-sharing measures, only medical services deductible showed an association with decreased MOUD initiation. Policy and benefit design should consider ways to reduce cost barriers to initiation and retention in MOUD.