Background: Buprenorphine offers unique therapeutic benefits in both pain management and addiction medicine through its partial μ-opioid agonist and κ-opioid antagonist properties, providing effective analgesia with reduced abuse potential and respiratory depression risks compared to full μ-opioid agonists.1 The relationship between inadequately controlled pain and opioid use disorder (OUD) development involves multiple factors including opioid exposure, individual susceptibility, and central sensitization.2,3 Given these correlations and buprenorphine’s more favorable safety profile, it presents as a potentially advantageous first-line opioid analgesic option for patients with risk factors for OUD, undiagnosed OUD, or comorbid pain and OUD.1,4 Despite these advantages, buprenorphine remains underutilized. In the United States, multiple buprenorphine formulations have Food and Drug Administration (FDA) approval with distinct indications for either analgesia or medication treatment of opioid use disorder (MOUD). This study aimed to quantify the financial burden of each buprenorphine formulation for patients with differing insurance coverage plans and, when possible, compare this price to the payer acquisition cost.

Methods: We conducted a cross-sectional analysis of buprenorphine formulation costs using multiple data sources (IRB #00122891) following CHEERS guidelines for economic analysis in healthcare (https://bit.ly/41IlV3B). Patient out-of-pocket data were derived from the IQVIA Longitudinal Prescription Claims database (January–December 2023) for commercial insurance, self-pay, Medicaid, and Medicare Advantage Part D coverage. GoodRx (https://www.goodrx.com) was used for discounted self-pay prices (November 2024). Payer acquisition costs, or the cost an insurance company or government entity will pay to acquire a medication, were analyzed using National Average Drug Acquisition Cost data (October 2024), Medicare Part D Pricing Public Use File (Q3 2024), and Federal Supply Schedule for Veterans Affairs pricing (November 2024). Cost comparisons were standardized using equianalgesic doses from FDA-approved prescribing information.6 We analyzed minimum available costs (out of pocket and acquisition for patients and payers, respectively) for each formulation type and FDA indication, calculating monthly and annual expenditures for each payment category and computing relative cost ratios between pain and OUD formulations (R version 4.2.0).

Results: Analysis revealed consistent patient out-of-pocket cost disparities between pain and OUD formulations across categories (Table 1 and Figure 1). Medicare beneficiaries faced a 6.6-fold difference between the least expensive pain and OUD formulations (monthly range: $5.62–$76.94 for OUD vs. $37.22–$109.45 for pain formulations). Commercial insurance patients showed moderate disparities ($18.63–$57.58 for OUD vs. $39.89–$109.45 for pain formulations). Self-pay patients encountered the highest costs, with monthly OUD formulation expenses ranging from $94.64 to $360.10 and pain formulations from $363.92 to $1324.13. Discount programs provided some relief, but costs remained substantial. Most Medicaid beneficiaries and Veterans with 100% service-connected disability ratings (https://www.pbm.va.gov) have subsidized out-of-pocket costs resulting in near zero and zero, respectively, patient payments at the pharmacy counter.