Drug formularies not a top legislative priority this year

Illinois is the only state to introduce legislation this year to create a workers compensation drug formulary, despite the documented success of such regulations in limiting the prescribing of addictive pain medications to injured workers.

But experts say they don’t see the issue of opioid prescribing in comp fading as other strategies are at play.

Formularies — lists of prescription drugs approved for use by workers with injuries that are now in place in 17 states — are just one piece of the puzzle, they say.

“State drug formularies are highly successful,” said Joe Semkiu, Schaumburg, Illinois-based national medical director with Zurich North America. In California, for example, a drug formulary led to “fewer claimants being prescribed opioids early in the course of their treatment and for shorter durations, lessening the possibility for addiction and dependency,” he said.

Illinois H.B. 3558, introduced Feb. 18 and pending in the House Rules Committee, aims to enact an evidence-based formulary by Sept. 22.

Lawmakers in Pennsylvania, where formulary legislation has failed several times, have expressed interest in revisiting the issue this year, while Louisiana could consider a formulary soon, according to Brian Allen, Salt Lake City-based vice president of government affairs, pharmacy solutions, for Mitchell International Inc.

“Opioids are still on the front line for regulators,” Mr. Allen said, adding that some states — for example, Utah, which recently extended prescribing limits for acute pain — are amending regulations to better align with new research.

“I think you will see in years going forward they will start revisiting what they have done and see what’s working and make some tweaks,” he said.

Preliminary data released by the Cambridge, Massachusetts-based Workers Compensation Research Institute at its annual conference in March showed that formularies have been effective in reducing opioids, as most require multi-step utilization reviews for most opioid prescriptions.

In California, where a workers comp formulary went into effect in 2018, per-claim drug utilization and payments fell “immediately” after implementation, according to WCRI. For opioids alone, there was a 38% reduction in prescriptions for injured workers between the fourth quarter of 2017 and the second quarter of 2018.

Another study by WCRI, released last year, found that other state policies had a hand in reducing opioids for injured workers. Prescription drug monitoring programs – put in place in the past five years — reduced the amount of opioids prescribed by 12% in the first year of implementation, and regulations limiting the duration of initial opioid prescriptions resulted in a 19% decrease in the amount of opioids in workers compensation claims.

Meanwhile, the National Council on Compensation Insurance in 2021 found no difference between formulary states and non-formulary states when it came to opioid prescribing.

This likely stems from opioid prescribing laws and greater awareness that have led to a decline in prescriptions for pain medications, said Raji Chadarevian, director of medical regulation and informatics at Boca Raton, Florida-based NCCI. He noted in particular regulatory and legislative changes and individual practitioners holding the line on prescribing opioids.

“It’s hard to eke out the impact of the formulary on opioids (because) there is a lot more attention being paid,” he said.

Mr. Chadarevian said he expects the march toward formularies to continue, as the National Conference of Insurance Legislators in 2020 adopted model legislation to help states create workers comp formularies.

Reema Hammoud, Southfield, Michigan-based assistant vice president of clinical pharmacy for Sedgwick Claims Management Services Inc., said formularies help insurers and third-party administrators better question opioid prescriptions for injured workers, putting in place protocols for utilization reviews.

“We have seen a nice shift in opioid (prescribing), and I think it is the result of everything that has gone into effect at the different state levels,” she said.

This article was first published in Business Insurance.

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