June 22, 2018
As the spotlight on the opioid epidemic has become brighter and brighter, the tolerance for creating management strategies has increased. I remember even just a couple of years ago hearing managed care professionals within small to mid-sized organizations express a desire to begin putting restrictions beyond quantity limits and DUR messaging in place, but that they felt stuck without the support of larger organizations or government entities. The fear most expressed was that by implementing restrictions providers and members were not used to seeing would lead to confusion and potential barriers for members to get treatments that they needed.
Since that time, the strategies from government entities and the larger players in the managed care industry have evolved. I want to take an opportunity to review some of these strategies in hopes that it will stir some of these small- to mid-sized managed care organizations to implement similar strategies knowing that providers and members now expect to see them. This is not meant to be a comprehensive listing of every strategy and every organization implementing these strategies, rather this is meant to be a summary of the most visible strategies and players.
The most asked about strategy clients have come to me about is limiting the day supply on first-time opioid fills. I believe the interest in the type of strategy stems from the CDC's guideline's citation of a few studies that the use of opioids beyond a certain number of days following low-risk surgery increases the risk of opioid dependence. Up to 18 states have enacted legislation that will lead to a limit of the day supply for a new opioid user between 3 to 14 days. CVS Caremark, Express Scripts, and Walmart pharmacies have announced restrictions within their membership and patient population to limit new opioid users to a maximum of 7 days of opioids. The continued legislation and nationwide announcements of these restriction is getting this message to every prescriber.
Restrictions on the daily dose of opioids measured in morphine equivalents was championed by CMS with a number of organizations following the pattern. Most of these limits will return a hard rejection once the daily dose of an opioid is exceeded. Some have also implemented soft rejections for pharmacies to be notified if the submitted claim exceeds a certain daily limit. Nation-wide organizations that have announced these kinds of restrictions include CVS Caremark, Express Scripts, and Walmart along with many state governments have brought this kind of restriction to light among prescriber and patient populations.
Along with the morphine equivalent restriction championed by plans providing services under the CMS flag, there has been a combination of other metrics such as the number of opioid prescribers or the number of pharmacies filling an opioid to a member. Private organizations such as Prime Therapeutics have combed multiple data points into a scoring system that will drive a restriction on opioid coverage when a member has exceeded a point threshold. Other organizations have taken a similar approach of scoring their members' risk of opioid abuse or misuse and using these scores to create member outreach programs. Combining clinical outreach with hard restrictions is becoming more and more common especially in health plan populations.
I am encouraged to see these and many other innovative strategies coming from so many organizations and government bodies nationwide. None of these strategies alone will solve the opioid problem, but I think they have already begun to help. I have anecdotally been asked by more friends, family, and patients about these kinds of restrictions and why they are put into place. In many of these cases I have been able to provide information to help them chose appropriate opioid use. My hope is that providers and pharmacists are using opioid restrictions as an opportunity to educate patients so patients can make potentially life-saving choices in their opioid use. I also hope that the expansion of opioid restrictions will prompt smaller managed care organizations to continue to align their restrictions with confidence in the ever-expanding knowledge of restrictions by providers and members.
—Russ J Spjut, PharmD
Russ J Spjut, PharmD, is owner of Formulary Intel Consulting. He is a residency trained pharmacist in managed care with experience in both commercial and Medicare Part D PBM operations. He has been involved in formulary management, P&T committee presentations, clinical program development, formulary strategy, clinical analysis, client management, and review of coverage determination requests for a major health care management company.
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