Study: Formularies may be key to alleviating opioid epidemic


New Yale University research offers stunning findings about drug formulary coverage and prescribing opioids.

Health plan formularies present a wasted opportunity to restrict opioid prescribing, according to a new report.

The brief research report, published in Annals of Internal Medicine, assessed how utilization management strategies have been used by Medicare Part D formularies to restrict prescription opioids. A team of Yale University researchers found that Medicare Part D formularies allowed unrestrictive coverage for many opioids over the past 10 years, especially at high doses, including for drugs commonly associated with overdose.


Lead study author Elizabeth A. Samuels, MD, MPH, department of Emergency Medicine, Yale University, and colleagues, conducted a descriptive analysis of median formulary restrictiveness (defined by quantity limit, limits on prescribed morphine milligram equivalents [MME] per day, and requirements for prior authorization or step therapy) for 45 opioid drug-dosage combinations.

Formulary restrictiveness is one strategy to limit opioid prescribing. One private insurer showed that implementing prior authorization, quantity limits, and provider-patient agreements was associated with a 15% decrease in opioid prescribing. This study assessed the extent to which opioids are covered and/or restricted among Medicare formularies

Interpreting the data

Using data from CMS, the researchers compared coverage for all available doses of commonly used short- and long-acting opioid medications except for methadone. They found that more than two thirds of drug-dosage combinations had no opioid prescribing restrictions in 2006 and 2011 and approximately one-third had no restrictions in 2015. While quantity limits and prior authorization to restrict daily allowable prescribed dosing increased over the years, unrestrictive coverage persisted for many opioids.

“Medicare Part D formularies increasingly implemented quantity limits to restrict daily allowable dosage of prescription opioids from 2006 to 2015,” Samuels says. “Prior authorization and step therapy requirements were less commonly utilized, but also increased over time. Despite increasing restrictiveness, coverage of many prescription opioids remained unrestricted, especially at higher doses. Decreased restrictiveness at high doses was primarily because quantity limits remained the same regardless of dose.”

Managed care executives can be a part of addressing the opioid overdose epidemic, she says.

"Opioid prescription misuse is directly linked to the development of opioid use disorder and opioid overdose death,” says Samuels. “One way managed care executives can help address this epidemic is by utilizing formulary restriction strategies examined in this study, as well as increasing coverage of evidence-based addiction treatments, such as medication assisted treatment.” 

The researchers suggest that managed care executives examine how their formulary restrictiveness can encourage adherence to the 2016 CDC prescribing guidelines, including the utilization of quantity limits, limiting prescribed MME per day, as well as requiring step therapy or prior authorization prior to initiation of prescription opioids.

“I would also recommend increasing coverage for addiction treatment, specifically medication assisted treatment,” Samuels says.

Read next: Two opioid use disorder drugs to watch


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