Health plans should continue to refine their formulary when new data emerge about how these policies improve health or cause harm. Health plans should also ensure their prescribers and members have access to buprenorphine and naloxone, and that pharmacies in the health plan’s network are actively stocking and dispensing these lifesaving drugs. In this section we share examples of how health plans revised their formularies to support safer pain management as well as how health plans have worked with their prescribers and communities to ensure access to buprenorphine and naloxone.

  • Reduce new starts: How to reduce new opioid starts through appropriate formulary policies and effective communication with your provider network
  • Streamline access to MAT: How to streamline access to buprenorphine and naloxone through benefit design and pharmacy and prescriber support

Reduce New Starts

Health plans should regularly review their formulary policies to ensure they are aligned with best practices and emerging research on dosage, quantity limits, and formulations. Concerns are emerging that policies restricting opioid access for opioid-dependent patients with chronic pain may do harm instead of improve patient safety. Health plans should work with their provider network to understand where policies may create barriers to safer pain management and work quickly to resolve such barriers. In this section we provide examples of health plan communications to providers regarding policy changes as well as clinical guidance from the Centers for Disease Control and Prevention and health plans regarding opioid prescribing and nonpharmacological pain management.

 

Icon of a question mark

How to Do It

  1. Align formulary policies with best practices on dosage, quantity limits, formulations, fraud and abuse, etc.
  2. Understand where current policies may create obstacles to appropriate pain management or cause harm.
  3. Work with prescribers to determine what modifications may be needed to reduce the risk of unintended consequences.
  4. Implement and communicate any change.

 

Icon of person talking

Health Plan Stories

Kaiser Permanente Southern California

Kaiser Permanente Southern California adopted the American Academy of Emergency Medicine’s Emergency Department Opioid Prescribing Guidelines for the Treatment of Non-Cancer Related Pain (PDF).

Kaiser Permanente Southern California (KPSC) adopted the American Academy of Emergency Medicine’s Emergency Department Opioid Prescribing Guidelines for the Treatment of Non-Cancer Related Pain (PDF). KPSC stopped offering injectable opioids for the exacerbation of chronic noncancer pain in the emergency department (ED) and would offer only short-course prescriptions (i.e., up to 12 pills) for patients presenting with acute pain. ED physicians and staff assessed whether patients were candidates for medication-assisted treatment (MAT) and referred candidates to KPSC’s addiction medicine team for follow-up. KPSC coupled this effort with an educational campaign in the ED and achieved very high compliance across its Southern California EDs.
Show More

L.A. Care Health Plan

L.A. Care works with its pharmacy benefit manager to do retrospective drug utilization review.

L.A. Care works with its pharmacy benefit manager (PBM) to do retrospective drug utilization review. RDUR identifies prescribers whose patients are at risk of opioid overdose or death due to a combination of prescribed opioids with benzodiazepines and skeletal muscle relaxants. It also identifies patients using nine or more Schedule II–V drugs and/or who have obtained opioid prescriptions from multiple prescribers and pharmacies over a four-month period. The PBM sends letters to prescribers that relates the risk of overdose and death for their patients. The letters have resulted in a steady reduction in opioid prescribing across L.A. Care’s lines of business, including Medi-Cal. Members who obtain prescriptions at three or more pharmacies and from three or more prescribers in a 90-day period may also be locked in to a single pharmacy.
Show More

Partnership HealthPlan of California

Partnership HealthPlan of California analyzed prescription claims data to identify members on high doses of opioids as well as prescribers with patterns suggesting risk for adverse patient outcomes.

Partnership HealthPlan of California (PHC) analyzed prescription claims data to identify members on high doses of opioids as well as prescribers with patterns suggesting risk for adverse patient outcomes. PHC slowly advanced policies to support safe tapers to lower doses: first, requiring authorization for dose augmentation above a high-dose threshold, and then over time, requiring providers to submit justification for ongoing treatment with high doses, either attesting that the patient has had the high dose approved by a peer-review committee, or submitting a tapering plan to a lower dose. Exceptions to tapering were granted for medical or psychiatric instability; tapering was judged to be unsafe in about 17% of patients. The medical director and his team investigated prior authorization requests individually and promptly, and worked with prescribers to help them create individualized plans to lower doses where safe and appropriate.
Show More

 

Icon of a hammer

Tools

 

Icon of a stack of books

Resources

Streamline Access to MAT

Access to buprenorphine and naloxone can save lives. It is paramount that health plans ensure that their prescribers and patients have access to these drugs. Health plans should work with their networks to ensure buprenorphine and naloxone are available at all points in the health care system: hospitals, emergency departments, primary care clinics, mental health clinics, and addiction treatment programs. Plans must also work with pharmacies serving their members to ensure they are stocking and furnishing naloxone. In this section we share stories of health plans partnering with pharmacies and coalitions to ensure naloxone is available in their communities. We also include resources on naloxone prescribing and overdose training for providers.

 

Icon of a question mark

How to Do It

  1. Remove authorization requirements, copays, and annual limits for buprenorphine and naloxone.
  2. Work with pharmacy network to support stocking and furnishing naloxone.
  3. Promote co-prescribing (of naloxone) in your network.
  4. Promote medication-assisted treatment (MAT) in your network.

 

Icon of person talking

Health Plan Stories

Aetna

Beginning in January 2018, Aetna waived copayments for Narcan for fully insured commercial members in an effort to increase access and remove financial barriers to the lifesaving drug. Narcan is a brand-name version of naloxone. Prior to being waived, the copayment for Narcan ranged from $0 to $150. When Aetna waived the copayment, it also took steps to limit the quantity of opioids that could be prescribed for acute pain and post-surgery, limiting prescribers to a seven-day supply for commercial pharmacy members.

Aetna, Anthem, and Cigna

Aetna, Anthem, and Cigna removed the prior-authorization requirements for Suboxone in late 2016 (Cigna) and early 2017 (Aetna and Anthem). Anthem and Cigna implemented the change after facing an investigation by New York’s attorney general into whether the insurers’ coverage practices impeded patient access to necessary treatment. California’s Medi-Cal program removed the prior authorization requirement for Suboxone in 2015, and quickly saw a significant increase in use.

Central California Alliance for Health

Central California Alliance for Health is working with pharmacies in Merced to stock and furnish naloxone.

Central California Alliance for Health (CCAH) is working with pharmacies in Merced to stock and furnish naloxone. This has required one-on-one meetings between the health plan’s leadership (medical director and pharmacy director) and local pharmacies. The efforts to stock naloxone initially faced resistance from pharmacists due to concerns that making naloxone available would increase risky behavior and the likelihood of overdoses. Through ongoing dialogue, CCAH and the pharmacies have been able to work through this issue and bring naloxone into the Merced community.
Show More

Health Plan of San Joaquin

Health Plan of San Joaquin collaborates with local organizations in the San Joaquin County Opioid Safety Coalition run by San Joaquin Public Health Services.

Health Plan of San Joaquin (HPSJ) collaborates with local organizations in the San Joaquin County Opioid Safety Coalition (SJCOSC) run by San Joaquin Public Health Services. HPSJ is one of the partner agencies selected to serve on the accelerator team (a program of the California Opioid Safety Network) that helps guide the coalition. Other organizations represented include health care providers, community organizations, law enforcement, first responders, and educators.

The SJCOSC was initiated in March 2018. Its aim is to reduce deaths attributed to opioids. With partner enthusiasm and expertise, the coalition has been able to conduct training, community assessments, strategic planning, educational outreach, and group-based academic detailing. An early coalition effort focused on working to prevent overdose deaths by launching a naloxone distribution program. The goal was to distribute naloxone to the friends and family members of people at risk of overdose. To date, the coalition has given away over 900 naloxone kits received through a grant from the California Department of Public Health.

As each of the SJCOSC partners works with urgency and care to test and implement effective solutions, each also is committed to the guiding principle that any measurable, lasting solutions must be woven into an integrated menu of approaches.

Show More

Partnership HealthPlan of California

Partnership HealthPlan of California has taken steps to increase access to naloxone and designed a program that involves prescribing it in conjunction with opioids for patients identified by providers as having a high risk of opioid misuse.

Partnership HealthPlan of California (PHC) has taken steps to increase access to naloxone and designed a program that involves prescribing it in conjunction with opioids for patients identified by providers as having a high risk of opioid misuse. Unfortunately, the nasal spray version of naloxone was originally not on the state’s drug formulary — and the drug was carved out and managed by the state’s Medicaid fee-for-service program. To increase access to naloxone and make the drug easier to use, the plan began to provide nasal atomizers to provider sites treating members, in conjunction with a naloxone toolkit that includes best practices and guidelines to help educate providers about prescribing it. Fortunately, the state has since added the nasal spray to its formulary.
Show More

Santa Clara Family Health Plan

In 2015, Santa Clara Family Health Plan implemented a policy requiring authorization review for doses above 120 morphine milligram equivalents.

In 2015, Santa Clara Family Health Plan (SCFHP) implemented a policy requiring authorization review for doses above 120 morphine milligram equivalents (MME). Requests were automatically approved with a letter stating:

“This quantity of narcotics exceeds safe prescribing guidelines. Please co-prescribe naloxone injection, one vial, for overdose rescue.”

In 2016, recognizing that prescribers rarely read approval letters (and members never receive them), SCFHP created a new protocol. All requests for doses greater than 90 MME (excluding hospice and palliative care) were automatically denied unless a claim for naloxone was on file for that member. Denials triggered a letter to the prescriber and member stating:

“This quantity of narcotics greatly exceeds safe prescribing guidelines. Per Centers for Disease Control guidelines, opioid dosages greater than 90 MME per day are associated with increased risks. [For members receiving high-risk combinations of medications, the letter also read ‘The prescribed dosage and combination with morphine sulfate, oxycodone/APAP, and clonazepam are in the lethal range.’] Please resubmit with a prescription for naloxone injection, one vial, for overdose rescue.”

Once the naloxone prescription is documented, the authorization request is approved. With this approach, the health plan gives a clear message to the member and prescriber about safety without the labor-intensive practice of reviewing each case.

Show More

University of Pittsburgh Medical Center

University of Pittsburgh Medical Center covers and promotes overdose education and the use of naloxone products to prevent overdoses. The plan has provided substantial financial assistance to first responders to distribute naloxone kits, and in October 2016 provided information about naloxone to thousands of providers in the community.

 

Icon of a hammer

Tools

 

Icon of a stack of books

Resources