Nevada’s new law to combat the rising number of opioid deaths has drawn a public outcry from doctors and patients who say it is stymying access to necessary medications, but recent changes to insurer and pharmacy management policies have largely flown under the radar in the conversation.

Several insurance companies, responding to both public pressure to combat the opioid epidemic as well as guidelines issued by the Centers for Disease Control and Prevention, instituted changes nationwide at the beginning of the year, limiting the initial prescription of opioids for acute pain to seven days and requiring prior authorization for long-acting opioids. The biggest pharmacy benefit managers, responsible for negotiating drug prices between manufacturers, insurance companies and pharmacies, also have recently put limits on initial fills of opioid prescriptions.

The policy changes take effect amid a larger conversation in Nevada about how to balance laws and regulations aimed at preventing opioid overdoses with ensuring that patients who actually need pain medication receive it in a safe and responsible way. Proponents of the new opioid law attribute the initial pushback against it to doctors being uninformed about how to follow it, a problem that can be solved through education, while others say the law is inherently flawed and in need of fixing.

The insurance company and pharmacy benefit manager (PBM) policies are yet another method of combating opioid deaths. But they also are creating another layer of paperwork and rules for doctors to follow as they navigate compliance with the new Nevada law and can complicate things for patients.

“There are unintended consequences with these artificial restrictions,” said Dr. Jim Marx, a pain specialist in Las Vegas.

For instance, Aetna started limiting the quantity of opioids prescribed for acute pain and post-surgery to a seven-day supply starting Jan. 1. Any prescription greater than seven days requires prior authorization, to ensure providers are not overprescribing in an acute pain setting, an Aetna spokeswoman said.

“Physicians and members can always appeal denials for prescriptions, including for opioids,” said Aetna spokeswoman Anjie Coplin in an email.

Aetna also requires prior authorization for all long-acting opioids in order to ensure the medicines are being appropriately used, Coplin said. The prior authorization process takes into account whether the patient is undergoing treatment for cancer or receiving end-of-life care. Long-acting opioids can be covered for up to six months at a time for chronic pain, but lifetime coverage can be granted for end-of-life or cancer diagnoses.

Health Plan of Nevada and Sierra Health and Life, two United Healthcare subsidiaries providing insurance in Nevada, started requiring prior authorization for patients on their commercial plans taking long-acting opioids or those cumulatively taking more than 180 morphine equivalent doses starting on Jan. 1. Medicaid patients on Health Plan of Nevada have been subject to prior authorization for long-acting opioids since July.

Starting Thursday, commercial customers on the two plans and Medicaid patients on Health Plan of Nevada are now only able to receive initial prescriptions of opioids for up to seven days and no more than 49 morphine equivalent doses on their first prescription if they are new to opioid therapy. (There are no restrictions on a second prescription as long as it doesn’t meet the other criteria for prior authorization.)

Other insurance companies started rolling out limits over the last couple of years. Anthem Blue Cross Blue Shield started limiting initial prescriptions of short-acting opioids to seven days for some drugs in October 2016, and all short-acting opioids were subject to the limit in July. Anyone covered by Anthem can only receive a maximum of a 14 day supply for short-acting opioids in a 30-day period without prior authorization. The company also implemented a prior authorization process for long-acting opioids in September 2016 for initiation of therapy.

Pharmacy benefit managers have also adopted their own policies as far as the drugs they’ll cover. CVS Caremark, one of the three largest pharmacy benefit managers, started limiting initial prescriptions of opioids for acute pain for patients who are new to therapy starting Feb. 1. The new policy also limits daily dosages and requires that immediate-release formulations or drugs be given before extended-release versions are prescribed. Doctors can ask for exemptions for certain patients and employers and insurers are allowed to opt out of the new policy.

Express Scripts, another of the big three, started limiting patients new to opioid therapy to a seven-day supply on a short-acting opioid on Sept 1. OptumRx now limits members naive to opioid therapy to 49 morphine-milligram equivalent per day, with up to two seven-day fills in a 60-day timeframe starting July 2017.

The policy changes come as a reaction to guidelines issued by the CDC in 2016 as far as appropriate prescribing of opioids for both acute and chronic pain. They also come amid increased focus on the role that insurance companies and pharmacy benefit managers have played in the opioid crisis.

The limits on opioids seem like a good idea at face value, Marx said, but don’t always work out the way you think they’re going to in practice.

Marx gave the example of a chronic pain patient who takes 200 morphine milligram equivalents (MME) a day. Because patients who take higher amounts of opioids at one time are more likely to become addicted, doctors like to use as low a dose as possible as many times a day that a patient requires it. However, he said he’s run into situations where pharmacy benefit managers will approve two 100 MME doses but not four 50 MME ones.

“They want the patient to take one big pill, presenting a situation where the patients are presented with larger doses of medication, less times a day, and more likely to develop a liking for that medication,” Marx said.

Prescribers also have to be cognizant of the fact that although Nevada’s new opioid law allows them to write initial prescriptions for up to 14 days, a patient’s insurance may only pay for seven days.

Larry Pinson, executive secretary of the Board of Pharmacy, said that he hasn’t heard of issues between insurance companies, PBMs and pharmacists in response to the new policies because whether or not the prescription can be filled is usually decided right on the spot in the pharmacy. But he said it makes sense for insurers to set their own policies on opioids.

“I think in the long run, if you look at it empirically, it makes sense for insurance companies to look at those sorts of things,” Pinson said. “What good is it going to do to pay for narcotics for forever if someone gets addicted?”