Pharmacy Benefit Manager Safety Measures for Opioids for Dental Pain
In 2020, Elevance Health’s pharmacy benefit manager, CarelonRx, implemented a new policy for commercial and Medicaid members, limiting coverage for opioids to treat acute dental pain to no more than three days. This change led to meaningful reductions in prescription volume and dosage as well as member utilization of opioids for dental pain.
Approximately 125 million opioid prescriptions were dispensed to Americans in 2023. Anyone who takes prescription opioids can develop opioid use disorder (OUD), a problematic pattern of opioid use that causes significant impairment or distress. When prescription opioids are necessary, the best approach is to try the lowest effective dose and quantity.
Health plan and PBM clinical safety policies ensure access to needed medications while reducing use of prescription medications that have the potential for misuse, abuse, or diversion, such as opioids prescribed for pain. This brief demonstrates the positive impact of CarelonRx’s opioid clinical safety edits on dental prescriber behavior and member utilization, which contributed to notable declines in opioid overdoses.
Related Public Policy Research
Integrated Care Improves Outcomes for Opioid Use Disorder in West Virginia
Opioid use disorder (OUD) can have significant behavioral and physical health effects. Data demonstrates improved outcomes for Medicaid members with opioid use disorder in West Virginia through integrated care delivered by a Medicaid managed care plan.
A New Approach to the Opioid Crisis: Pandemic-Informed Solutions
The opioid epidemic is projected to claim 1.2 million U.S. lives this decade without new efforts to stem the crisis. Policymakers can leverage COVID-19 pandemic era learnings, such as the use of telehealth, the continuation of cross-state licensure, and the employment of peers, to implement measures that support sustained access to evidence-based solutions for the delivery of care to individuals with OUD.
PBMs are companies that administer the prescription drug benefit for health plans and employers. PBMs add value in three primary ways: improving health outcomes using evidence-based clinical programs, effectively managing pharmacy networks, and using financial management strategies to reduce prescription drug spending and costs.
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