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    Four PBM programs poised to rein in the opioid epidemic


    2. Prime Therapeutics’ controlled substance management program

    Prime’s program is grounded in its industry-validated controlled substance score, which has garnered the interest of government agencies and healthcare organizations nationally and helps identify risk of potential opioid misuse, says Prime’s senior vice president, chief medical officer Jonathan Gavras, MD. “It helps us get to the members who are at highest risk and intervene before a tragic outcome occurs,” he says.

    The controlled substance score is calculated using a three-month period of prescription claims data and is divided into three components:

    1.                   The controlled substance score counts the number of controlled substance claims and assigns 0.5 points for the first eight controlled substance claims and then one point for each additional claim.

    2.                  The number of unique pharmacies and unique prescribers are counted and assigned points; one for the first two unique entities and 1.5 for each unique entity thereafter.

    3.                  Points are assigned if the  number of controlled substance claims in the third month of the quarter is two or more than in the second month.

    Prime’s “controlled substance score” methodology is publicly available for other healthcare organizations to use.

    The controlled substance management program also includes:

    ·                     Prescriber outreach when patients have a high “controlled substance score.”

    ·                     Point-of-sale alerts, which notify pharmacists of potential concerns.

    ·                     Prior authorizations and quantity limits.

    ·                     Direct member interventions and enrollments in pharmacy homes or single prescribers.

    ·                     A team dedicated to examining integrated medical and pharmacy data to analyze program outcomes.
    “As a pharmacy benefit manager that is highly integrated with our Blue Plan clients across the country, we are uniquely positioned to use both pharmacy and medical data to identify controlled substance/opioid misuse,” Gavras says. “We see the repetitive claims, the multiple prescribers and pharmacies, and provide a complete tool set for prescribers and pharmacists to help us address potential misuse and even prevent it from occurring in the first place.”

    The next phase of the program is to develop a predictive modeling tool, which will launch shortly after press time, Gavras says. “This tool will help further reduce controlled substance misuse by identifying individuals who are early in their opioid use and have characteristics similar to those known to have levels of unsafe use,” he says. “Prime can then work upstream with prescribers and help educate members on dangers so misuse can be avoided before it ever starts.”

    Next: Express Scripts' solution



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