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    Four PBM programs poised to rein in the opioid epidemic


    Pharmacy benefit managers (PBMs) are well suited to address the opioid epidemic—and, it’s imperative that they do so, according to industry experts.

    “PBMs are uniquely positioned to connect and partner with physicians, pharmacists, patients, pharmaceutical manufacturers, health systems, and other components of the industry, and therefore are better able to drive improvements in education surrounding the dangers of opioid therapy, as well as the various tools available for constituents to positively change the course of this epidemic,” says Managed Healthcare Executive Editorial Advisor David Calabrese RPh, MHP, OptumRx’s chief pharmacy officer. “Our nation’s indiscriminate prescribing, dispensing, demand for, and consumption of prescription opioid drugs has led to a scenario in which we now consume more than 80% of the world’s supply of prescription opioids and a corresponding death toll due to opioid overdose which is one of the highest in the world,” says Calabrese. 

    Here are four PBM programs that demonstrate promising outcomes:

    1. OptumRx’s opioid risk management program

    This program addresses the epidemic using a connected clinical strategy comprising clinical capabilities and analytics, as well as care management and behavior tools. It targets:

    • Prevention and education;

    • Minimizing early exposure;

    • Reducing inappropriate supply;

    • Treating plan participants who are at risk and high risk; and

    • Supporting chronic populations and recovery.

    “What makes Opioid Risk Management most unique is how we leverage tools and resources that extend beyond traditional PBM-only core capabilities,” says Calabrese, noting that due to the PBM’s affiliation with Optum, a technology-enabled health services business, it is easier to take a deeper dive into data and analytics.

    The tools that deliver the most immediate and impactful change are point-of-service utilization management edits that align with CDC best practice guidelines, says Calabrese. These include limitations on the daily morphine-equivalent dose (MED) and the days’ supply of an opioid prescription. These also include limits on the daily MED dose of opioid prescription drugs for chronic utilizers at both an individual drug level and at a cumulative (across opioid prescriptions) level. Finally, these include edits that block opioid prescriptions from processing if a physician has lost controlled drug prescribing authority via the DEA or other entity, and drug utilization screening for dangerous combinations of opioid drugs and opioids with other therapies.

    “All of this is designed to decrease unnecessary exposure to prescription opioid therapy that can lead to future dependency and overdose risk in these individuals,” Calabrese says.

    Next: Prime's controlled substance management program



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