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National Trend: Pharmacy Benefit Managers Setting Limits on Opioid Prescriptions

CVS Caremark will become the latest pharmacy benefit manager to limit opioid prescriptions in certain cases, in an effort to better align with the Centers for Disease Control and Prevention's (CDC) Guideline for Prescribing Opioids for Chronic Pain.

Other large national pharmacy benefit managers have also announced changes to their opioid management strategies to align with CDC recommendations. Here's a look at new opioid management strategies from three major U.S. pharmacy benefit managers:

1. CVS Caremark—The policy, which will take effect on Feb. 1, 2018, includes dispensing requirements such as:

  • Limiting to seven days the supply of opioids dispensed for certain acute prescriptions.
  • Limiting the daily dosage of opioids dispensed based on the strength of the opioid.
  • Requiring the use of immediate-release formulations of opioids before extended-release opioids are dispensed.

CVS Pharmacy locations will also strengthen counseling and safe use education for patients filling an opioid prescription.

Learn more on CVS' website and its press release. To access CVS Caremark resources and contact information for physicians, click here.

2. Express Scripts—Although the Pennsylvania Medical Society (PAMED) was unable to obtain a copy of Express Scripts new policy, a CBS/Associated Press report says that the policy took effect on Sept. 1, 2017, and limits new opioid users to seven-day prescriptions. Other features of Express Scripts' new Advanced Opioid ManagementSM strategy outlined on website here include:

  • Prior authorization process through which physicians can provide additional information to the plan so their patients can obtain coverage for a longer-term supply or a long-acting opioid, as needed.
  • Notifying physicians in situations in which their patient has accumulated more than 200 mg morphine-equivalent dose/day of opioid medication.

For Express Scripts resources and contact information for physicians, click here.

3. Optum Rx—This pharmacy services company that is a part of UnitedHealth Group launched an opioid management program on July 1, 2017, with 400 clients, and announced in August 2017 that it is rolling out the program nationwide. Features of its quantity limit changes on short acting opioids include:

  • Beneficiaries with no opioid therapy in their most recent 120-day claims history will be limited to a maximum of 49 morphine-milligram equivalents (MME) per day; up to two 7-day supplies within a 60-day timeframe.
  • Beneficiaries who have filled an opioids prescription in their most recent 120-day claims history will be limited to a maximum of 90 morphine-milligram equivalents (MME) per day and subject to two fills within a 60-day timeframe.Get more details on the policy here. For Optum Rx resources and contact information for physicians, click here.

Additional Resources

For more information on the CDC's opioids prescribing guidelines, access these CDC resources:

The guidelines are not intended for patients who are in active cancer treatment, palliative care, or end-of-life care, the CDC says.

The Pennsylvania Department of Health – in collaboration with stakeholders including PAMED – has also developed a series of opioid prescribing guidelines for several medical specialties. Find them online at www.pamedoc.org/OpioidGuidelines

For PAMED resources on the opioid abuse crisis, visit www.pamedsoc.org/OpioidResources

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