Express Scripts Limits Opioid Prescriptions


The PBM giant is cutting down on the number of opioids new patients can buy.

Express Scripts is unveiling a new program aimed at reducing the number of opioids prescribed and dispensed. The PBM says that this new program, which begins September 1, will help reduce risks while still helping patients manage their pain.

For patients new to an opioid therapy, their first prescription will be limited to a 7-day supply. They will be asked to use a short-acting opioid initially, and not to exceed 200 mg MED/day. Jennifer Luddy, Director of Communications at Express Scripts, told Drug Topics that the prescriber “has a pathway (prior authorization) to provide us with more information and obtain more medication,” should there be a clinical need.

Physicians will receive an automated message through their EHR/EMR portal to inform them of potential duplicate therapy, misuse or abuse, drug-drug interactions, or if a patient is attempting to use multiple pharmacies. They will also receive an MED safety alert from Express Scripts if one of their patients exceeds a dose of 200mg MED/day.

Related article: Express Scripts Lowers Drug Prices For Some Patients

After that, Luddy said, the physician can submit a prior authorization request for additional medication if needed. “It is possible,” she said, “for the physician to not be aware that the accumulated amount is reaching that safety limit, and decide that it is not safe for the patient to have any more medication, which is why that alert is so important. We have had physicians call and thank us for alerting them in this regard.”

She said that Express Scripts has been improving its prior authorization process, and that doctors can use Express Scripts’ prior authorization portal either directly through their EMR vendor system or through a browser-based portal.

Pharmacists need to be aware of the initial 7-day-supply limit and 200 mg MED/day dosing, as well as the requirement for prior authorization for all long-acting opioids to new opioid-therapy patients. Luddy added that the concurrent drug utilization review “will also ensure opioid prescriptions are appropriate, medically necessary, and unlikely to result in adverse medical consequences.”

Patients will receive a letter after their first fill to educate them on the dangers of opioid use, along with safe-handling instructing, restrictions, and proper disposal methods. Express Scripts’ team of opioid neuroscience specialist pharmacists (ONSP) will provide outreach to patients where the data “signals concerning patterns of use,” according to Luddy. She gave the example of a patient attempting to fill two or more different short-acting opioids within 30 days.

Related article: How to Beat the Opioid Crisis

Express Scripts will also provide patients with disposal bags for first-time users who are unlikely to require their full dose, which will allow them to dispose of unneeded medication directly from home. Patients will be limited to one pharmacy (a lock-in) for filling their prescription, when Express Scripts’ fraud waste and abuse program detects drug-seeking behavior.

Up next: Who is excluded from the program?


Luddy stressed that this program will only apply to Express Scripts members whose plan provider enrolls in the program. She also added that these rules will not apply to patients in hospice, in palliative care, or with cancer, “because we do not want to delay their access to needed pain therapy.”

The goal of the program, according to Luddy, is to reduce unnecessary opioid dispensing, such as “where a patient with acute pain who has never used an opioid gets more opioid medication than they really need; for example, a patient getting a 22-day Rx for a tooth extraction.” She also mentioned that one in five patients who start on a 10-day supply end up as long-term users, and 70% of abused prescription medications come from family and friends, many of whom have unused and unnecessary medication.

Related article: Express Scripts Kicks Out EpiPen Competitors

Express Scripts ran a pilot study of the program with 100,000 Express Scripts members new to opioid therapy. They observed a 38% reduction in hospitalizations and 40% reduction in emergency room visits in patients who received an educational letter intervention, according to Luddy. A subset of that group receiving letters who were deemed more at risk also received a counseling call from an OSNP, and among this group, they observed a 19% decrease in the day’s supply of opioid during a six-month follow-up.

CVS Caremark, another PBM, currently has a

similar rule

placing a 10-day, 90 MME/day limit on new opioid prescriptions.

Overall, Luddy said that the program was built by analyzing opioid use among members and listening to client concerns. “Patients got the medicine they need while we helped prevent unnecessary refills that could put patients at risk of significant harm,” she said.

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