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phys­i­cal ther­apy, said Christo­pher M. Jones, a se­nior pol­icy of­fi­cial at the de­part­ment.

In­sur­ers say they have been ad­dress­ing the is­sue on many fronts, in­clud­ing mon­i­tor­ing pa­tients’ opi­oid pre­scrip­tions, as well as doc­tors’ pre­scrib­ing pat­terns. “We have a very com­pre­hen­sive ap­proach to­ward iden­ti­fy­ing in ad­vance who might be get­ting into trou­ble, and who may be on that tra­jec­tory to­ward be­com­ing de­pen­dent on opi­oids,” said Dr. Mark Fried­lan­der, the chief med­i­cal of­fi­cer of Aetna Be­hav­ioral Health who par­tic­i­pates on its opi­oid task force.

Aetna and other in­sur­ers say they have seen marked de­clines in monthly opi­oid pre­scrip­tions in the past year or so. At least two large phar­macy ben­e­fit man­agers an­nounced this year that they would limit cov­er­age of new pre­scrip­tions for pain pills to a seven- or 10-day sup­ply. And bow­ing to pub­lic pres­sure — not to men­tion gov­ern­ment in­ves­ti­ga­tions — sev­eral in­sur­ers have re­moved bar­ri­ers that had made it dif­fi­cult to get cov­er­age for drugs that treat ad­dic­tion, like Subox­one.

Ex­perts in ad­dic­tion note that the opi­oid epi­demic has been chang­ing and that the prob­lem now ap­pears to be rooted more in the il­licit trade of heroin and fen­tanyl. But the po­ten­tial for ad­dic­tion to pre­scribed opi­oids is real: 20 per­cent of pa­tients who re­ceive an ini­tial 10-day pre­scrip­tion for opi­oids will still be us­ing the drugs af­ter a year, ac­cord­ing to a study by re­searchers at the Uni­ver­sity of Arkansas for Med­i­cal Sciences.

Sev­eral pa­tients said in in­ter­views that they were ter­ri­fied of be­com­ing de­pen­dent on opi­oid med­i­ca­tions and were un­will­ing to take them, de­spite their pain.

In 2009, Amanda Jantzi weaned her­self off opi­oids by switch­ing to the more ex­pen­sive Lyrica to treat the pain as­so­ci­ated with in­ter­sti­tial cys­ti­tis, a chronic blad­der con­di­tion.

But ear­lier this year, Jantzi, who is 33 and lives in Vir­ginia, switched jobs and got a new in­surer — An­them — which said it would not cover Lyrica be­cause there was not suf­fi­cient ev­i­dence to prove that it worked for in­ter­sti­tial cys­ti­tis. Jantzi’s ap­peal was de­nied. She can­not af­ford the roughly $520 monthly re­tail price of Lyrica, she said, so she takes generic gabapentin, a re­lated, cheaper drug. She said it does not man­age the pain as well as Lyrica, which she took for eight years. “It’s in­fu­ri­at­ing,” she said.

Jantzi said she wanted to avoid re­turn­ing to opi­oids. How­ever, “I could see other peo­ple, faced with a sim­i­lar sit­u­a­tion, say­ing, ‘I can’t live like this, I’m go­ing to need to go back to painkillers,’” she said.

In a state­ment, An­them said that its mem­bers have to meet cer­tain re­quire­ments be­fore it will pay for Lyrica. Mem­bers can ap­ply for an ex­cep­tion, the in­surer said. Jantzi said she did just that and was turned down.

With Bu­trans, the drug that Erkes was de­nied, sev­eral in­sur­ers ei­ther do not cover it, re­quire a high out-of-pocket pay­ment, or will pay for it only af­ter a pa­tient has tried other opi­oids and failed to get re­lief.

In one case, Op­tumRx, which is owned by Unit­edHealth Group, sug­gested that a mem­ber tak­ing Bu­trans con­sider switch­ing to a “lower cost al­ter­na­tive,” such as OxyCon­tin or ex­tended-re­lease mor­phine, ac­cord­ing to a let­ter pro­vided by the mem­ber.

Wig­gin, the Unit­edHealth­care spokesman, said the com­pany’s rules and pre­ferred drug list “are de­signed to en­sure mem­bers have ac­cess to drugs they need for acute sit­u­a­tions, such as post-sur­gi­cal care or se­ri­ous in­jury, or on­go­ing cancer treat­ment and end of life care,” as well as for long-term use af­ter al­ter­na­tives are tried.

Bu­trans is sold by Pur­due Pharma, which has been ac­cused of fu­el­ing the opi­oid epi­demic through its ag­gres­sive mar­ket­ing of OxyCon­tin. Bu­trans is meant for pa­tients for whom other med­i­ca­tions, like im­me­di­ate-re­lease opi­oids or an­ti­in­flam­ma­tory pain drugs, have failed to work, and some sci­en­tific analy­ses say there is not enough ev­i­dence to show it works bet­ter than other drugs for pain.

Dr. An­drew Kolodny is a critic of wide­spread opi­oid pre­scrib­ing and a co-di­rec­tor of opi­oid pol­icy re­search at the Heller School for So­cial Pol­icy and Man­age­ment at Bran­deis Uni­ver­sity. Kolodny said he was no fan of Bu­trans be­cause he did not be­lieve it was ef­fec­tive for chronic pain, but he ob­jected to in­sur­ers sug­gest­ing that pa­tients in­stead take a “cheaper, more dan­ger­ous opi­oid.”

“That’s stupid,” he said.

Erkes’s pain spe­cial­ist, Dr. Jor­dan Tate, said her pa­tient had been sta­ble on the Bu­trans patch un­til Jan­uary, when Unit­edHealth­care stopped cov­er­ing the prod­uct and de­nied Erkes’s ap­peal.

With­out Bu­trans, Erkes, who once vis­ited the doc­tor ev­ery two months, was now in Tate’s of­fice much more fre­quently, and once went to the emer­gency room be­cause she could not con­trol her pain, thought to be re­lated to an au­toim­mune dis­or­der, Be­hcet’s dis­ease.

Tate said she and Erkes re­luc­tantly set­tled on ex­tend­e­drelease mor­phine, a drug that Unit­edHealth­care ap­proved with­out any prior au­tho­riza­tion, even though mor­phine is con­sid­ered more ad­dic­tive than the Bu­trans patch. She also takes hy­drocodone when the pain spikes and Lyrica, which Unit­edHealth­care ap­proved af­ter re­quir­ing a prior au­tho­riza­tion.

Erkes ac­knowl­edged that she could have con­tin­ued with fur­ther ap­peals, but said the process ex­hausted her and she even­tu­ally gave up.

While Tate said Erkes had not shown signs of abus­ing painkillers, her sit­u­a­tion was far from ideal. “She’s in her 20s and she’s on ex­tend­e­drelease mor­phine — it’s just not the pretty story that it was six months ago.”

Dr. Shawn Ryan, who runs an ad­dic­tion treat­ment prac­tice in Cincinnati, said too many in­sur­ance com­pa­nies put oner­ous bar­ri­ers on pa­tients need­ing med­i­ca­tions to treat their ad­dic­tions. (An­drew Spear for The New York Times)

Many ex­perts who study opi­oid abuse say they also are con­cerned about in­sur­ers’ lim­its on ad­dic­tion treat­ments. Some state Med­i­caid pro­grams for the poor, which pay for a large share of ad­dic­tion treat­ments, con­tinue to re­quire ad­vance ap­proval be­fore Subox­one can be pre­scribed or they place time lim­its on its use, both of which in­ter­fere with treat­ment, said Lind­sey Vuolo, as­so­ciate di­rec­tor of health law and pol­icy at the Na­tional Cen­ter on Ad­dic­tion and Sub­stance Abuse. Drugs like Subox­one, or its generic equiv­a­lent, are used to wean peo­ple off opi­oids but can also be mis­used.

The anal­y­sis by ProPublica and the Times found that re­stric­tions re­main preva­lent in Medi­care plans, as well. Drug plans cov­er­ing 33.6 mil­lion peo­ple in­clude Subox­one, but two-thirds re­quire prior au­tho­riza­tion. Even when such re­quire­ments do not ex­ist, the out-of-pocket costs of the drugs are of­ten un­af­ford­able, a num­ber of phar­ma­cists and doc­tors said.

At Dr. Shawn Ryan’s ad­dic­tion-treat­ment prac­tice in Cincinnati, called BrightView, staff mem­bers of­ten take pa­tients to the phar­macy to fill their pre­scrip­tions for ad­dic­tion med­i­ca­tions and then watch them take their first dose. Re­search has shown that such over­sight im­proves the odds of suc­cess. But when it takes hours to gain ap­proval, some pa­tients leave, said Ryan, who is also pres­i­dent of the Ohio So­ci­ety of Ad­dic­tion Medicine.

“The guy walks out, and you can’t blame him,” Ryan said. “He’s like, ‘Hey man, I’m here to get help. What’s the deal?’”

ProPublica deputy data edi­tor Ryann Gro­chowski Jones con­trib­uted to this re­port.

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