What Are Insurance Coverage Policies for Drug Treatments for Low Back Pain?

Bottom Line: An analysis of prescription drug coverage policies for the treatment of low back pain suggests insurers could help to reduce opioid overuse by expanding access to opioid alternatives through coverage and reimbursement policies.

Why The Research Is Interesting: Little is known about medication coverage policies among U.S. insurers for the treatment of chronic noncancer pain.

Who, What and When: Health plan documents from 15 Medicaid, 15 Medicare Advantage and 20 commercial health plans in 2017 from 16 states representing more than half of the U.S. population; 20 interviews with more than 43 senior medical and pharmacy health plan executives from representative plans

What (Study Measures and Outcomes): Formulary coverage, utilization management and patient out-of-pocket costs

How (Study Design): This was an observational study. Researchers were not intervening for purposes of the study and cannot control all the natural differences that could explain the study findings.

Authors: G. Caleb Alexander, M.D., M.S., Johns Hopkins Bloomberg School of Public Health, Baltimore, and coauthors


Study Limitations: Publicly available documents were not consistently available for all payers; some health systems and payers, such as the Veterans Health Administration and workers’ compensation plans, weren’t included.

Study Conclusions: The findings suggest opportunities for insurers to redesign coverage policies to improve pain management and reduce opioid-related injuries and deaths.

Related material: The commentary, “Opioid Prescribing for Low Back Pain,” by Jennifer F. Waljee, M.D., M.P.H., and Chad M. Brummett, M.D., of the University of Michigan, Ann Arbor is also available on the For The Media website.

To Learn More: The full study is available on the For The Media website.