From Health Plan Week

Tighter Restrictions, Community Grants Aid Blues’ Efforts to Help Combat Opioid Misuse

Reprinted from HEALTH PLAN WEEK, the most reliable source of objective business, financial and regulatory news of the health insurance industry. Subscribe today!

By Jane Anderson
July 3, 2017Volume 27Issue 23

Blue Cross and Blue Shield insurers are beefing up restrictions on initial opioid prescriptions, implementing high-risk member programs and making other changes to their opioid prescription and addiction treatment policies in an effort to combat the increasing epidemic of opioid overdoses.

Independence Blue Cross, which has been active in the opioid epidemic task force led by Philadelphia Mayor Jim Kenney (D) , is adding stringent rules on initial opioid prescriptions. Meanwhile, other Blues plans are stepping up grant funding to community and state organizations that are combatting opioid addiction.

But these moves come as the Addiction Solutions Campaign — led by four leading non-profits in the addiction field — released a June 21 report calling on insurers and regulators to take a hard look at legal obligations to ensure that patients receive the full benefits of existing parity laws covering mental health and substance abuse disorders.

The report specifically mentioned prior authorization for medication-assisted treatment and other utilization measures as harmful barriers to care. American Medical Association opioid task force chair Patrice Harris, M.D., said the report “should be a wake-up call that too many patients face significant hurdles in accessing care.”

Beginning this month, Independence Blue Cross will restrict opioid prescriptions to no more than five days for initial low-dose opioids, while allowing longer use for cancer-related pain and hospice patients.

“This safeguard prevents multiple opioid prescriptions from being filled at different pharmacies and reduces the risk for addiction while addressing legitimate pain treatment,” Richard Snyder, M.D., Independence’s chief medical officer and senior vice president, tells AIS Health. “We are hopeful that this will have a significant effect on over-prescribing, but also on access to unused medications by unintended people.”

Independence also regularly distributes and promotes Centers for Disease Control and Prevention (CDC) prescribing guidelines to doctors, and that’s been effective, Snyder says. “For example, after providing more than 1,250 of our network doctors a list of their patients who were prescribed more than the CDC-recommended doses of opioids, nearly 65% of those physicians stopped inappropriate prescribing.”

Health Plan Week

Opioid Restrictions Result in Lower Use

Since 2014, Independence has reduced inappropriate opioid use among members by nearly 30%, Snyder says. The insurer requires initial and ongoing prior authorization on all high dose use of opioids, including a full work-up of patients’ underlying cause for pain and implementation of more targeted therapy when available, he says. Independence also requires a patient-provider agreement, which helps patients understand their responsibilities regarding treatment, for long-term use of opioids, he says.

Also, beginning in August, Independence will provide coverage for addiction treatment medication methadone. The insurer does not require initial prior authorization on buprenorphine products, but does require precertification at six months to ensure the member is still involved in addiction therapy and is not just using the medication in isolation, Snyder says.

In May, Independence said its IBC Foundation will partner with Public Health Management Corporation, a non-profit in Philadelphia, to conduct a study of the “warm handoff protocol,” a referral practice intended to move patients who have just overdosed directly into the care of behavioral health consultants.

Anthem, Inc., meanwhile, is continuing a year-old program intended to limit high-risk members to the use of one pharmacy in an effort to prevent them from filling multiple prescriptions from different providers. The program, called Pharmacy Home, launched in April 2016.

The program notifies members in writing that they could be moved into the program. It also notifies prescribers in writing of the decision to include the member in the program, and gives the prescriber a three-month member prescription history, along with an educational brochure on the advantages of using one pharmacy for the provider to review with the member. The program’s goal is to intervene early in order to prevent a substance abuse disorder from developing.

Anthem Medicaid plans have seen large drops in opioid prescriptions from similar programs. To be eligible for the program, Anthem members must have met these criteria within a 90-day period:

  • Filled five or more controlled-substance prescriptions, or filled 20 or more prescriptions in total (not limited to controlled substances).

  • Visited three or more health care providers for controlled substance prescriptions, or 10 or more providers in total (not limited to controlled substances).

  • Filed controlled substance prescriptions at three or more pharmacies, or filled prescriptions at 10 or more pharmacies in total (not limited to controlled substances).

The program covers high-risk members in individual and employer-sponsored plans. Members with a diagnosis or prescription history indicating HIV, sickle cell anemia, multiple sclerosis, cancer, hospice or palliative care are exempt. Anthem also has agreed to end its preauthorization policy for medication-assisted treatment for opioid use disorder.

Blues Partner With Community Groups

Several Blues insurers are providing grant money to non-profits in their states to combat opioid addiction and assist with public education efforts.

Last year, BlueCross BlueShield of Tennessee began requiring prior authorization for long-term opioid prescriptions. In addition, the insurer’s BlueCross BlueShield of Tennessee Health Foundation teamed up with the state Department of Health and the Coffee County Anti-Drug Coalition to expand a public health information campaign called “Count It! Lock It! Drop It!”

As part of the campaign, the Tennessee Blues plan’s foundation is providing $1.3 million in grant money to help counties with high rates of opioid addiction. The campaign, which was begun in 2011 by the anti-drug coalition, urges people to count their spare pills, lock them up, and drop off their unneeded pills at a law enforcement drop box.

In Michigan, Blue Cross Blue Shield of Michigan, its foundation, and three other non-profits are banding together to allocate $455,000 for one-time grants aimed at reducing opioid and prescription drug abuse. The funders say they will support projects in up to seven Michigan communities over 18 months.

Coalitions that are eligible for the grants must be made up of medical, mental health and substance abuse treatment providers; public health and public safety organizations; and other community organizations, such as schools. According to the Michigan Blues plan, the number of deaths in Michigan from drug overdose more than tripled between 1999 and 2015.

Access the Addiction Solutions Campaign report at

Get timely, objective business, financial and regulatory news of the health insurance industry each week with your own subscription to AIS's Health Plan Week. Learn more and subscribe today!

Copyright © 2017 Managed Markets Insight & Technology, LLC. All Rights Reserved.

It's quick and easy to sign up for FREE access to!

Why do I need to register?

Resources for Paid Subscribers
Not a Paid Subscriber?

Check out all of the benefits, sample issues & more!