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The opioid epidemic continues to dominate news headlines.

July 24, 2017


At Prime, we have been leading controlled substance management for more than a decade. We know our approach to managing opioids is working; we’ve seen a 16 percent decrease in opioid claims over the past five years for our commercial book of business, comparing the first half of 2012 to the first half of 2017. 

Yet, opioid misuse remains a major issue both socially and fiscally and we are constantly looking for new, innovative ways to continue the fight against it. We know that combating this epidemic requires a multi-pronged approach, and that is why we have launched the Controlled Substance Management Program.

There is no single solution

Combining new and existing offerings, our program aims to identify members who are at risk of controlled substance misuse and has interventions and products in place to help reduce their risk.

The program brings together all of our current and new controlled substance efforts into a comprehensive approach, including:

  • A controlled substance (CS) score: identifies individuals at risk of controlled substance misuse.
  • Concurrent drug utilization review (DUR): screens prescriptions at the point of sale for potential drug-therapy problems.
  • Utilization management: includes prior authorizations and quantity limits to help members who need prescription pain drugs have access while avoiding the potential for overuse or misuse.
  • Formulary management: includes exclusions in NetResults and preferred drug strategy for opioids.
  • GuidedHealth®: uses medical and pharmacy claims data to analyze and identify opportunities to improve member care by addressing overuse and drug safety. GuidedHealth also includes prescriber outreach.
  • New GuidedHealth Care Program: includes case management and may enroll members in a pharmacy or prescriber home for their controlled substance medicines to increase safety for members at risk for misuse. 
  • A research team dedicated to examining Prime’s integrated medical and pharmacy data to analyze program outcomes and dashboard outlier utilization at a client level.

CS score making an impact and driving innovation 

Prime has made its CS Score algorithm publicly available, and it has served as a model to government agencies and health care organizations for identifying risk of misuse of controlled substances. We found that a one point decrease in a member’s CS score was associated with decreases in1:

  • $1,488 total cost of care
  • $235 in CS drug costs
  • 0.9 percent hospitalization rate
  • 1.5 percent ER visit rate

With the success of the CS score, Prime is working on designing a predictive modeling tool to launch in 2018. 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. Prime will be positioned to work upstream with prescribers and help educate members on dangers so misuse can be avoided before it ever begins. Having the ability to work upstream in preventing opioid misuse is key to combating the epidemic.

Uniquely positioned to lead the way and help others join the fight 

Our best minds are actively involved in the national conversation, presenting our studies to the Academy of Managed Care Pharmacy (AMCP) and joining panels with the Institute for Clinical and Economic Review (ICER). Our research is thoroughly peer reviewed and published. 

Because we are deeply integrated with the Blue Cross and Blue Shield plans we serve, we see the opioid epidemic differently – across the medical and pharmacy spectrum. We can see members’ use whether it’s after hospitalization or from the doctor’s office to the pharmacy.

We invite you to learn more about our multi-faceted approach to controlled substance management. Please contact your Prime representative to learn how to help keep your members free from the harms of opioids. 

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  • 1 Starner, Cathy. (March 2015). A Controlled Substances (CS) score: is it related to healthcare utilization and total cost of care? Presented at Academy of Managed Care Pharmacy.
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