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Coverage Policies Compared for Back Pain Medications

Utilization management common for opioids; often relies on 30-day limits rather than prior authorization

MONDAY, June 25, 2018 (HealthDay News) — There are opportunities for recalibrating the role of opioids in pain care, including expanding access to opioid alternatives through coverage and reimbursement policies, according to a study published online June 22 in JAMA Network Open.

Dora H. Lin, M.H.S., from the Johns Hopkins Bloomberg School of Public Health in Baltimore, and colleagues examined medication coverage policies for 30 prescription opioids and 32 non-opioids used to treat low back pain in a study of health plan documents from 15 Medicaid, 15 Medicare Advantage, and 20 commercial health plans.

The researchers found that the Medicaid plans covered a median of 19 opioids and 22 non-opioids examined; Medicare Advantage plans covered 17 opioids and 22 non-opioids; and commercial plans covered 23 opioids and 26 non-opioids. Utilization management strategies were common for opioids in Medicaid plans, Medicare Advantage plans, and commercial plans (median, 15, 15, and 16, respectively) and generally relied on 30-day quantity limits instead of prior authorization. Many of the non-opioids were also subject to utilization management, especially quantity limits and prior authorization. According to informant interviews, there was an emphasis on increasing opioid utilization management and identifying high-risk prescribers and patients rather than promoting comprehensive strategies to improve chronic pain treatment.

“These findings provide an important opportunity to evaluate how formulary placement, utilization management, copayments, and integration of non-pharmacologic treatments can be optimized to improve pain care while reducing opioid-related injuries and deaths,” the authors write.

Two authors disclosed financial ties to the pharmaceutical and technology industries.

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