Pharmacy Benefit

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.

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.

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.

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.

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.

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.

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.