Q&A with BBBA: Can a health plan impose a “fail-first” requirement for opioid use disorder treatments?

December 12, 2017

Q: Can a health plan impose a fail-first requirement for opioid use disorder treatments before authorizing coverage for Medication Assisted Treatment (MAT)?  The MAT is more costly, and involves both counseling and medication.

A: First, let’s define a fail-first requirement, it is a health plan provision that excludes coverage of higher-cost treatments until a participant demonstrates that a lower-cost treatment is not effective.  An organization’s plan requirement that participant try, and fail, at counseling alone before the plan will pay for medication assisted treatment (MAT) would be considered a fail-first requirement.  When a fail-first requirement is applied to benefits for substance use disorders such as an opioid use disorder, that requirement is a treatment limitation that must comply with the federal mental health parity rules.

To be in compliance with federal mental health parity rules, your plan cannot impose a fail-first requirement on MAT coverage for opioid use disorder unless the processes, strategies, standards, and other factors considered by the plan in designing and imposing the requirement are applied no more stringently, and comparable to, those used in applying fail-first requirements to medical/surgical prescription drug benefits.

Therefore, if your plan does not impose fail-first requirments before authorizing coverage for medication for other medical/surgical conditions, but comparable standards and other factors indicate that fail-first requirements would be appropriate, then the MAT fail-first requirement would be a treatment limitation that the plan applies more stringently to a substance use disorder condition than to medical surgical conditions. The disparity between the two requirements would violate the mental health parity rules, unless an exemption applies (ie., an increased cost exemption).


For more information regarding Employee Benefits and “Fail-First” Requirements for your organization, or to speak with one of our advisors, email Phyllis LoSapio at plosapio@advisorsbb.com.

Brown & Brown Benefit Advisors