Insurers restricting high-risk opioid users to select pharmacies

July 1, 2016

As the opioid epidemic continues to get worse, some health insurers are blocking patients identified as “high risk” from getting multiple opioid prescriptions filled at various pharmacies by restricting where they can fill prescriptions.

As the opioid epidemic continues to get worse, some health insurers are blocking patients identified as “high risk” from getting multiple opioid prescriptions filled at various pharmacies by restricting where they can fill prescriptions.

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Lisa Morris, AnthemMore people died from drug overdoses in the U.S. in 2014 than during any previous year on record, according to the CDC, with nearly half a million people in the United States dying from drug overdoses between 2010-2014. Notably, at least half of all opioid overdose deaths involve a prescription opioid.

Early into Anthem’s Pharmacy Home Program to prevent opioid abuse and polypharmacy, the insurer has already identified high-risk patients and plans to start curbing opioid scripts filled by those patients. In May, Anthem began notifying members identified as “high risk” for opioid abuse that they would be enrolled in the program, which limits drug coverage to one member-chosen home pharmacy.

These patients can select the pharmacy of their choice. However, after that selection is made the insurer will only pay for opioid prescriptions dispensed by the selected pharmacy. “We have sent hundreds of letters out. It won’t be until July that we will have the first group of pharmacy members [in place],” said Lisa Morris, Anthem’s vice president of clinical and specialty pharmacy.

According to Anthem, it has found that 24% of members identified as “high risk” had filled 10 or more controlled substance prescriptions during a 90-day period. Plus, 13% filled controlled substance scripts at five or more pharmacies and 19% filled scripts from five or more prescribers during a 90-day period.

Morris is optimistic that Anthem’s program will produce similar results as its opioid abuse-deterrent program that was designed to identify high-risk members with the Medicaid program in Maryland. “We experienced an opioid-related spending decrease of 12%, driven by reductions in inpatient services, reduced emergency department [visits] and non-opioid prescription drug spending in our Medicaid program in Maryland,” Morris said.

 

Plus, as members decreased or stopped opioid use, they also enrolled at much higher rates in substance abuse treatment. “The important issue is that we are helping to re-direct members to appropriate care and hopefully preventing unnecessary adverse events and deaths,” Morris said.

In May, Cigna also announced a multi-pronged plan to curb opioid abuse, with the goal of reducing members’ opioid use by 25%. Cigna will limit the quantity of painkillers and explore “additional controls for high-risk customers identified by Cigna's data on its customers,” the insurer said in a statement.

Cigna is also supporting efforts to require prescribers to check state Prescription Drug Monitoring Program databases when prescribing more than a 21-day supply of a painkillers such as oxycodone or morphine, and is encouraging the rapid adoption of the new CDC guidelines on opioid use. Those guidelines include prescribing opioids for the shortest time possible to treat acute pain, and talking with patients about all options and risks before beginning long-term therapy.