Prime Therapeutics’ predictive model expands efforts to reduce potential misuse and abuse of opioids

Opioid registry now includes Medicare and Medicaid member identification

December 22, 2020

EAGAN, Minn. – In an effort to help identify both new and prior users of opioids who may be at risk for opioid use harm and to ultimately help prevent misuse, Prime Therapeutics LLC (Prime) is expanding its predictive models beyond Medicare, to now help members in Medicaid.

A recent survey¹ of Prime members across all lines of business showed 95% of respondents indicated the opioid epidemic was a serious issue in the U.S. today; 30% indicated it is one of the most serious issues. Prime’s survey also found that one-third of the members didn’t know whether a medicine they were prescribed was an opioid or not.

To assist with identification of members who may become at risk for opioid use harm in both the Medicare and Medicaid populations, Prime developed modeling that helps predict members who may be on a trajectory of reaching potentially dangerous opioid use. This information can then be shared with Prime’s health plan clients to assist with member outreach and education around appropriate opioid usage. Closing the awareness gap can empower members to make more informed decisions and better manage their opioid use.

Utilizing the opioid predictive model

Prime’s predictive model assesses the likelihood a member with an opioid prescription will reach the Centers for Disease Control and Prevention (CDC) morphine milligram equivalent (MME) daily threshold of concern in the next six months. This MME threshold indicates the daily opioid amount, in all opioid prescriptions, the member has received. The Centers for Disease Control and Prevention (CDC) defines high dose opioid therapy, which is associated with increased harm, as greater than or equal to 90 milligrams morphine equivalent (MME) daily dose. The models are divided into two groups because each group has different educational and management needs: new users (those with no opioid claims in past six months) and prior users (those who have had an opioid claim in the past six months).

Multiple model types were tested, and the best models were identified based on the accuracy of predictions driven by previous pharmacy claims data and identified potential predictive variables. Because members who are new to an opioid and members who are prior users have different habits and behaviors, different variables are needed to inform different models. Each predictive model uses variables such as days of supply, multiple claims counts, socio-demographics, prescriber information, other prescription claims data, and many others to assist with the identification of potential misuse.

“Prime’s ability to take previous claims data, analyze it and produce predictive models to identify potential health complications in the future is the kind of innovation our industry needs,” said Patrick Gleason, PharmD, assistant vice president of health outcomes at Prime. “Thanks to our opioid predictive model’s ability to leverage data strategically and generate actionable insights, our health plans clients are now able to make the best decisions for their members’ health.”

Leveraging predictive model in GuidedHealth®

Prime integrates the predictive model into its GuidedHealth opioid registry to help deliver value to clients. The registry contains member information to help feed the predictors in the model. GuidedHealth’s clinical rules engine identifies actionable insights to help members and their doctors make better medication management decisions.

GuidedHealth is currently piloting the efficacy of the models with the Medicare population of two health plans. Utilizing prescriber and member outreach, the pilots aim to validate if awareness, education and other recommendations for the new and prior opioid users is effective. Recommendations may include:

  • Enhancing existing case or disease management programs
  • Initiating dialogue with prescribers
  • Educating about CDC opioid use guidelines on overuse risk

If identified to be at risk of hitting or exceeding the MME threshold within the next six months, Prime sends letters to members and their most recent prescriber, educating them about safe opioid use and disposal and encouraging members to discuss opioid reversal drug naloxone with their provider. The year-long pilots will conclude in December, with results due early in 2021.

Learn about Prime’s controlled substance management program.


  1. Prime’s Customer and Market Insights team. (2020). [Prime Therapeutics Member Research Panel: Opioid Awareness]. Unpublished raw data.

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