Opioid Epidemic Spawns Flurry of PBM Programs to Address Abuse

Express Scripts, other major PBMs tighten controls on opioids

Abuse and overuse of opioids continues to be a hot topic as lawmakers and healthcare industry stakeholders take aim at programs to combat the epidemic. According to the Centers for Disease Control and Prevention, most overdose deaths involve an opioid and deaths from prescription opioids have increased 400 percent since 1999. For every reported death from opioids, 851 patients were in different stages of misuse, abuse and treatment, and one in five users who begin on a 10-day supply of opioid medication turns out to be long-term users.

The most commonly prescribed opioid analgesics, such as hydrocodone-acetaminophen, oxycodone-acetaminophen and Suboxone in the case of bone fractures, chronic pain or dental procedures, are very effective in pain management, however, these drugs are addictive, and are often associated with misuse, overdose deaths, emergency room visits and other adverse health consequences. Despite prescribing guidelines and evidence from clinical research, overprescribing remains a top concern. For pharma, what is emerging is a more restrictive environment when it comes to utilization controls for drugs in a crowded analgesic market for drugs that treat chronic pain.

Each of the largest PBMs in the nation has launched programs targeting opioid abuse. Express Scripts’ program and Advanced Opioid Management started September 1st, 2017, and is an extension of a preliminary program launched in 2016 that was tested on about 100,000 members. The PBMs opioid solution is intended to lower risk at each touch point of the care continuum which includes prescribers, pharmacies and patients. The results from the 2016 preliminary launch were positive, showing a 38 percent reduction in hospitalizations and a 40 percent reduction in emergency room visits among the intervention group compared to the control group during six months of follow up, according to Express Scripts.

Under the program, the first opioid prescription to the patient is restricted to a seven-day supply, regardless of the doctors’ prescription. The initiative also targets to limit the prescribed dosage and would prefer short-acting drugs to be prescribed for opioid-naïve patients instead of long-acting opioids. The physicians must seek prior-authorization to prescribe a long-acting opioid for first-time users. The Express Scripts program has drawn some criticism from the American Medical Association, which took exception with the restrictions on first-fill prescriptions regardless of the prescription and prior authorization limitations.

Express Scripts also plans to monitor the utilization patterns of the opioid users including prescriber and pharmacy utilization as patients misusing opioids generally seek out multiple prescribers and pharmacies, and if they identify such situation the PBM will notify the new patients and warn them regarding opioid misuse and addiction. For people who are already taking opioid analgesics, a daily dosage of no more than 200 mg Morphine-Equivalent Dose (MED) per day could be prescribed. In case of dosages exceeding those limits, the PBM will send a safety alert to the physician to monitor the case.

This Express Scripts program is not applicable to cancer patients and patients suffering from a life-threatening disease or receiving hospice care. The program’s foundation is also laid upon opioid prescribing guidelines issued by the Centers for Disease Control and Prevention for primary-care physicians in 2016 which recommends physicians to prescribe short-acting opioids initially and start the treatment with the lowest effective dosage for an opioid-naïve patient. The CDC cautions prescribers when prescribing dosages above 50mg MED and to avoid increasing dosages above 90mg MED.

CVS has a 10-day limit on opioids and it also limits the dosage and by default, the patients should start on short-acting drugs. The PBM also works with 41 states across the nation and have expanded access to Narcan, an opioid overdose reversal drug. CVS/Caremark also has a prescription drug monitoring program, which monitors the process to identify pill shopping and other forms of frauds. It also works with its retail pharmacies to review prescribing trends and identifies physicians and prescribers who shows extreme patterns of prescribing high-risk drugs. The PBM is also rolling out an enhanced opioid utilization management program for its commercial, health plan, employer and Medicaid clients on February, 1st, 2018, which will limit opioid supply to seven days for the new users.

In July 2017, Prime launched its Controlled Substance Management Program that combines existing and new programs to address opioid abuse and dependency. The program includes risk assessment score that identifies individuals at risk of controlled substance misuse, outreach through Prime’s GuidedHealth program, and direct member interventions. The PBM plans to launch a predictive modeling system in 2018 to further its drug abuse prevention programs.

OptumRx launched an opioid risk management program nationwide and has created predictive algorithms that calculate the exact morphine-milligram dosing equivalents (MME) for every opioid drug on the market, down to the individual drug, strength, and formulation level. These algorithms will ensure that a patient newly initiated on an opioid therapy is limited to less than or equal to a seven-day supply of medication based upon CDC dosing guidelines.

The move by PBMs to focus on opioids is in step with the heightened attention by federal and state lawmakers, health plans and other stakeholders. President Donald Trump has announced plans to declare opioid abuse a national emergency and FDA Commissioner Scott Gottlieb also wrote to 18,000 FDA employees calling for effective efforts against the opioid crisis. Across the nation, Medicaid programs have implemented prescription drug monitoring programs to track opioid prescriptions and implemented quantity limits, prior authorization, and other restrictions. Cigna has announced that they have achieved a 12 percent decline in patients who use prescribed opioids compared to last year and plans to remove prior authorization restrictions for commercial members seeking treatment for opioid addiction. Anthem which had limited the coverage for newly prescribed short-acting opioids to seven days for its members has announced that they have reduced the filled opioid prescriptions by 30 percent.

As noted in Decision Resource Group’s analysis of state markets through its Formulary Insights report series, the ability of PBMs to influence prescription drug utilization can vary widely between states. Likewise, the dynamics of influence between providers and payers vary greatly between geographic regions and that, too, could determine the effectiveness of these newly launched opioid-abuse programs. In states where there is a higher degree of integration between providers and payers, or where payers and PBMs are able to exert more influence, programs such as those being launched by PBMs are more likely to have a higher degree of success.


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The Formulary Insights report series provides analysis of the trends and market dynamics affecting formulary decisions and product opportunity in each U.S. state, Washington, D.C., and Puerto Rico. Each report includes our proprietary Opportunity Index, analysis of Value-Based and Innovative Contracting, and regulatory and policy matters. Formulary Insights are an enhancement of DRG’s Health Plan Analysis portfolio.