ST. PAUL, Minn., July 17, 2017 /PRNewswire/ -- A comprehensive program announced today by pharmacy benefit manager Prime Therapeutics LLC (Prime), which serves 14 Blue Cross and Blue Shield plans nationally, identifies members who are at risk of controlled substance misuse and gets them into programs that can help reduce their risk. Prime's "Controlled Substance Management Program" combines existing and new offerings into a multi-layered program to help address the national epidemic.
"Prime is uniquely positioned to use both pharmacy and medical data to identify misuse, and provide a complete toolset for prescribers and pharmacists to address potential misuse and poor outcomes," said Jonathan Gavras, M.D., Prime's chief medical officer. "This integrated approach to this problem is critical to saving lives."
The program builds on Prime's decade-long leadership in addressing the controlled substance crisis, which has contributed to a 16 percent decrease in opioid claims over the past five years for Prime's commercial book of business, comparing the first half of 2012 to the first half of 2017. A recent Prime study shows its controlled substance programs were associated with 6.4 percent fewer emergency room visits and reduced health care costs up to $1,500 per member per year.
The solution brings together Prime's current and new controlled substance efforts into a comprehensive approach, which includes:
- A "controlled substance score" which identifies individuals who are at high risk of controlled substance misuse
- Prescriber outreach through Prime's GuidedHealth® program, which uses pharmacy and medical data to alert prescribers to people who have a high "controlled substance score"
- Point-of-sale alerts, which notify pharmacists of potential concerns
- Prior authorization, which requires members to meet specific criteria before a controlled substance is covered, and quantity limits, which restrict the amount or frequency of dispensing a controlled substance
- Prevention, detection and correction of potential fraud, waste, and abuse of controlled substances by providers and pharmacies
- A new GuidedHealth® Care Program, which includes direct member intervention and may enroll members in a pharmacy home or single prescriber for their controlled substance medicines to increase safety for those members most at risk for misuse
- A research team dedicated to examining Prime's integrated medical and pharmacy data to analyze program outcomes
Prime's program is grounded in its industry-validated controlled substance score, which has garnered the interest of government agencies and health care organizations nationally and is serving as a model for identifying risk of misuse and abuse of controlled substances. Prime has made its model publicly available to contribute to safer controlled substance use nationally.
The success of current efforts has led Prime to develop predictive modeling to launch in 2018 to help further reduce controlled substance misuse. This tool will identify individuals who are early in their opioid use and have characteristics similar to those known to have levels of unsafe use. For example, this tool will cull our medical and pharmacy claims data to track characteristics such as age, gender, socio-economic factors, emergency department use, multiple prescribers, multiple pharmacies, and medical diagnoses, and generate a report of those who match characteristics that indicate possible high risk. Prime will be positioned to work upstream with prescribers and help educate members on dangers so misuse can be avoided before it ever starts. Preventing opioid misuse is key to slowing and eventually putting an end to this epidemic.
"Prime's comprehensive controlled substances offerings have served as a model for the industry and our programs have helped our members decrease their opioid claim volume by one-sixth in the past five years," said David Lassen, PharmD, Prime's chief clinical officer. "We are committed to continuing to take a leading role in developing new solutions to address this epidemic."
About Prime Therapeutics
Prime Therapeutics LLC (Prime) helps people get the medicine they need to feel better and live well. Prime manages pharmacy benefits for health plans, employers, and government programs including Medicare and Medicaid. The company processes claims and delivers medicine to members, offering clinical services for people with complex medical conditions. Prime serves more than 20 million people. It is collectively owned by 14 Blue Cross and Blue Shield Plans, subsidiaries or affiliates of those plans.
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SOURCE Prime Therapeutics