2017 Fall Newsletter- Payers Stepping Up to Tackle the Opioid Epidemic

Addressing the opioid epidemic is a key issue facing much of America.  President Trump recently stated that “this epidemic is a national health emergency.  As Americans, we cannot allow this to continue.”  To combat this epidemic will require a multi-faceted approach involving communities, law enforcement, prescribers, pharmacies, patients, and payers.  With stakeholders facing a heightened urgency to act, payers are increasingly looking for new ways to limit the overprescribing of prescription opioids.  In the past year, CVS Health, Express Scripts, Optum, and Cigna have all made recent statements and taken steps to limit patient access to opioid prescriptions.

The PBM CVS Health was the first to announce that they would limit opioid prescriptions to a 7-day supply for patients new to pain therapy.  Under the new plan, CVS will also limit the daily dose of opioids based on their strength and require use of immediate-release versions before extended-release options.  These benefit design changes will apply to CVS commercial, employer group, and Medicaid plans.

Express Scripts soon followed suit, limiting patients new to opioid therapy to a 7-day supply, regardless of the quantity prescribed.  Physicians prescribing an extended-release opioid to a first-time user will need to complete a prior authorization, incentivizing immediate-release product use first.  Similarly, the daily dose will be limited to 200 mg morphine-equivalent dose (MED), and prescribers wishing to have patients on higher doses will need to submit a prior authorization request.  The milligram-morphine-equivalent (MME) is a value assigned to a specific opioid to represent its relative potency, while the MED is the per-day sum of the MME potency score of all opioids a patient is prescribed.

Like the other PBMs, Optum is implementing a stricter program and limiting patients new to opioid therapy to a maximum of 49 MED per day.  New opioid patients can fill a maximum of two 7-day supplies within a 60-day period.  Non-cancer patients already taking opioids will be limited to a maximum of 90 MED per day with two fills in 60 days.

The American Medical Association is against the new PBM policies, with some physicians stating that the PBMs are “practicing medicine” and intruding on the doctor-patient relationship.  Other physicians welcome the monitoring, as they are unaware of patient relationships with multiple physicians and appreciate the oversight.  Although most physicians are appropriately monitoring opioid use, the new PBM plans will likely force other physicians to prescribe smaller quantity prescriptions for patients new to therapy.  Most importantly, the new PBM opioid plans have been shown to work.  Compared to the control group, an analysis of 106,000 patients enrolled in the Express Scripts pilot program showed a 38% reduction in hospitalizations and a 40% reduction in emergency room visits.

Many of the parties involved in addressing the opioid crisis are investing funds to curb abuse and address this societal issue.  Many pharmacies and physicians have already paid to integrate accessing Prescription Drug Monitoring Programs (PDMPs) into their software systems.  PHSI expects these PBM-set opioid prescription limits will become standard claims processing edits, but PBMs will likely recoup funds for processing any additional prior authorizations associated with the programs.

Cigna recently announced that they will stop covering OxyContin® prescriptions in “an attempt to reduce opioid use amid a nationwide abuse epidemic”.  This change applies to brand-name OxyContin.  No additional limits are placed on generic oxycodone or similar opioids.  Cigna recently signed a “value-based contract” with Collegium Pharmaceutical for Xtampza® ER, an oxycodone equivalent with abuse-deterrent properties.  Was this change made due to the lower street-value of Xtampza® compared to brand OxyContin?  Skeptics note this change appears to be financially and rebate-motivated versus a true patient-centered opioid reduction program.  It will be interesting to see decision outcome reports on Cigna’s change.

PHSI is hopeful that the new PBM quantity limits will curb opioid abuse.  These programs will not likely impact patients already on opioids at doses less than 200 mg MED/day, but will instead focus on new-starts.  With prescription opioids serving as gateway drugs, these new programs will hopefully prevent patients from escalating to heroin and other illicit substances.

 

2017 Fall Newsletter- PHSI Analysis of Authorized Generic Drugs