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Utilization management strategies for opioid and nonopioid medications in low back pain, including quantity limits and prior authorization, were found to be commonly used in Medicaid, Medicare Advantage, and commercial insurance plans, according to a study published in JAMA Network Open.
A total of 62 medications for low back pain, including prescription opioids (n=30) and nonopioid analgesics (n=32), were examined in the study. Coverage health plan documents from Medicaid (n=15), Medicare Advantage (n=15), and commercial health plans (n=20) were assessed. Data were pooled from a total of 16 states across the United States and represented approximately half of the population. In addition, interviews with senior medical and pharmacy health plan leaders were conducted and included in the analysis. The primary measures included formulary coverage, utilization management, and patient out-of-pocket costs.
Medicaid covered a median of 19 opioid medications (interquartile range [IQR], 12-27; median, 63%; IQR, 40%-90%) and 22 nonopioid drugs (IQR, 21-27; median, 69%; IQR, 66%-83%). A median of 17 opioids (IQR, 15-22; median, 57%; IQR, 50%-73%) and 22 nonopioid medications (IQR, 22-26; median, 69%; IQR, 69%-81%) were covered by Medicare Advantage plans. Commercial plans were associated with more extensive coverage of opioids (median [IQR], 23 [21-25]; 77% [70%-84%]) and nonopioids (median [IQR], 26 [24-27]; 81% [74%-85%]) compared with Medicaid and Medicare.
Utilization management strategies for opioids were found to be used with high prevalence in Medicaid plans (median interquartile range [IQR] 15 [95% CI, 11-20]; 91% [74%-97%]), Medicare Advantage plans (median IQR 15 [9-18]; 100% [100%-100%]), as well as commercial insurance plans (median IQR 16 [11-20]; 74% [53%-94%]). Typically, these plans relied on 30-day quantity limits vs prior authorization. Common utilization management strategies for the many nonopioid medications examined in the analysis included quantity limits (24%-32% of products across payers) and prior authorization (median IQR: commercial plans, 2 [0-3]; 9% [0%-11%]; Medicare Advantage plans: 4 [3-5]; 19% [10%-23%]; Medicaid plans: 6 [1-13]; 38% [2%-52%]).
Limitations of the analysis include the lack of reliability of the publicly available documents and the exclusion of other health plans, such as workers’ compensation or Veterans Health Administration plans.
“Our findings point to opportunities among insurers and pharmacy benefit managers to recalibrate the role of opioids in pain care, expand access to opioid alternatives through coverage and reimbursement policies, and measure the impact of such changes on patient outcomes,” concluded the study authors.
Reference
Lin DH, Jones CM, Compton WM, et al. Prescription drug coverage for treatment of low back pain among US Medicaid, Medicare Advantage, and commercial insurers. JAMA Network Open. 2018;1:e180235.
