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Helping Clients Manage Appropriate Utilization, Preserve Access
CVS Health's Response to Prescription Opioid Misuse and Abuse
Learn more about the results of our opioid utilization management criteria and read an overview of our enterprise-wide efforts to address the issue.
Virtually no part of our country and no walk of life has remained unaffected by the opioid crisis. CVS Health has made an enterprise-wide commitment to help address the abuse and misuse of prescription opioids.
Helping our clients manage utilization while providing appropriate patient access is an important component of helping address prescription opioid misuse and abuse given the risk of addiction and overdose associated with these potent medications. As a pharmacy benefit manager covering more than 90 million plan members, CVS Caremark can help its clients bring about positive change in opioid prescribing through carefully designed utilization management (UM) criteria. In the fall of 2017, we introduced our new utilization management (UM) criteria, which is aligned with the Guideline for Prescribing Opioids for Chronic Pain from the Centers for Disease Control and Prevention. Our criteria is designed to positively influence the prescribing and use of opioids to treat pain, while helping provide appropriate patient access.
CVS Health is utilizing our integrated model to focus on:
|Counseling and support|
|Access to overdose treatment|
Helping Reduce Misuse
Since implementation, approximately 2,300 clients accounting for nearly 30 million lives have adopted our CDC-aligned criteria. For clients who adopted the criteria, 94.3 percent of covered prescriptions for patients new to opioid therapy are for seven days or less compared to less than 80 percent for clients who did not adopt our criteria.
Balancing Access and Risk
Our UM criteria targets several areas of opioid prescribing and use. Based on the CDC Guideline, it:
- Limits days’ supply of opioids for acute prescriptions for patients new to opioids
- Limits the daily quantity of opioids
- Requires step therapy for use of immediate-release opioids before extended-release opioids for patients new to opioids
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However, it is important to balance the need to help clients reduce prescription opioid abuse with that of members with legitimate need based on their health condition. We have exceptions in place for members:
94.3% of all covered prescriptions for clients adopting our CDC-aligned criteria are now less than seven days compared to less than 80% for clients who have not adopted our CDC-aligned criteria. In addition, our communication efforts helped minimize member and prescriber disruption as a result of the CDC-aligned UM criteria. Since January, of those members who had an opioid claim rejected, only 0.7 percent appealed the decision, and only 3.3 percent called Customer Care.
Through a unique, enterprise-wide approach, CVS Health is working to help clients bring about positive change and reduce the risk of prescription opioid use and abuse in our communities.
Optimizing prescription therapy is key to improving outcomes for chronic conditions that drive a majority of health care spend.
Helping Lower Client Cost While Ensuring Members Have Access to Clinically Appropriate Medications.
Data source: CVS Health internal data unless otherwise noted.
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