More PBMs tackling opioids at the first fill as state comp laws evolve

Pharmacy benefits management firms are aligning their business with state laws on how much opioids an injured worker can be prescribed on the first fill of their prescriptions despite backlash from doctors, experts say.

“It’s actually standard now; you hear people complaining but there’s nothing to complain about,” said A.J. Ally, Kansas City, Missouri-based vice president of clinical strategy and programs for Argus Health Systems Inc. “Most of the PBMs have set up their claims business like this.”

Argus’ program limiting first fills to seven days was introduced earlier in 2017, said Mr. Ally, who was referencing recent comments made by an official with the American Medical Association regarding St. Louis-based Express Scripts Holding Co.’s new program that will also limit first-fill opioid prescriptions to seven days starting in September. Woonsocket, Rhode Island-based CVS Caremark Corp. — another large PBM — also has a similar program.

Dr. Patrice Harris, an Atlanta psychiatrist who chairs the American Medical Association's Opioids Task Force, released a statement saying doctors are already addressing the opioid epidemic and that limitations are unnecessary and could hurt patients already suffering.

“When patients seek physician help for an opioid use disorder — or need comprehensive care for chronic pain — one-size-fits-all limits, such as blanket prior authorization protocols, may cause delays in care that could severely harm patients,” she said in the statement. “While physicians continue to make important strides in making more judicious prescribing decisions — evidenced by the 17% nationwide decrease in opioid prescriptions since 2012 — it is critical that we prescribe opioids only when the benefits outweigh the risks.”

Despite the backlash from the country’s largest medical association, the need to control who receives opioids and how much is great, said Snezana Mahon, St. Louis-based vice president of clinical product development for Express Scripts.

“The percentage of overutilization keeps getting worse and worse (and) it was necessary for us to start taking a more stringent approach,” she said.

As of August, nine states have introduced or enacted legislation that limits prescriptions on the first fill — and more laws are in the works, she said.

Dr. Paul Peak, who oversees PBM vendors as an assistant vice president of clinical pharmacy for Sedgwick Claims Management Services Inc. in Memphis, Tennessee, said the trend is for the drug management firms to help enforce the laws.

“In the big picture in the opioid epidemic, how can we enforce the laws that are out there?” he said. “We know the risks (for addiction) increase with longer first fill. Why can’t the PBMs put processes in place?”

“In so many ways physicians out there … some are still not listening to what is being required by the law,” he said, adding that most PBMs are customizing their approach and offer wiggle room in the form of authorizations, in accordance with laws. 

Ms. Mahon said it’s become the duty of the PBMs to take over.

“(In some cases) these state regulations haven’t done enough (and) nobody is monitoring these patients,” she said. “That was the precursor for us to say, ‘we have to do something.’ We had that system where we were letting physicians manage it … but unfortunately the amount of drugs getting in the hands of patients early on caused this problem” with widespread opioid abuse.  

“With all this noise on this problem, with the states and federal government and the plans we are hoping there is seminal effect ... that (doctors) will start changing their behavior,” said Mr. Ally.