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PBMI Awards Anthem for its Opioid Management Program for Medicare Members


March 08, 2017

The Pharmacy Benefit Management Institute (PBMI) recently awarded one of the nation’s largest insurers, Anthem Inc, with its Excellence Award for Care Management Strategies for Anthem’s Opioid Overutilization Management Program.

To date, Anthem’s program, which is operated by Anthem’s Medicare plans, has reduced the number of at-risk members filing claims for opioids by approximately 50%.

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The program, originally developed to meet criteria from the Centers for Medicare and Medicaid Services, reviews the past years data of opioid use among its Anthem Medicare and Medicare-Medicaid dual enrollees to identify those at risk for potential opioid overuse. Members who have received a diagnosis of cancer, or are receiving hospice care, are excluded from the review. If a member exceeds the programs criteria on the number of prescribers, pharmacies and morphine equivalent daily doses, the member’s prescribers are notified.

“Often, prescribers won’t realize that the member is filling more prescriptions for opioids written by other prescribers,” Devanshi Sheri, clinical pharmacist who leads the program for Anthem’s Government Business Division, said in a press release. “Our program allows prescribers time to work with the members by looking at all their prescriptions and diagnoses holistically to assess their need for opioids.”

Case managers work in tandem with the prescribers to either keep a close watch on the member to allow time for a resolution or reduce benefit coverage at the pharmacy to prevent unsafe use, Dr Sheri explained. Additionally, the program may also refer at-risk beneficiaries to case management programs to help them begin addiction treatment.

As the opioid epidemic continues to grow, programs like Anthem’s can help to improve patient access to pain management treatment while also helping to reduce addiction risks among its beneficiaries. Anthem said that it intends to double its number of consumers who receive Medicare behavioral health services for opioid addiction, and they hope to reduce the number of opioids dispensed to their member by 30% between a 2012 peak and 2019.

Julie Gould (Mazurkiewicz)

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