Fighting Opioid Abuse: Our PBM’s Approach

Anne Klis, Vice President of Professional Practice and Training at CVS Health, explains how CVS Caremark, our prescription benefits management business, is working to combat the growing opioid abuse problem.

Opioid abuse has reached epidemic proportions, with deaths from prescription opioids more than quadrupling since 1999.Centers for Disease Control and Prevention While these medications often serve legitimate medical purposes, they also present a real risk for adverse health events, including addiction and overdose. Our goal as a company is to help the communities we serve address and prevent prescription drug abuse and misuse across all of our pharmacy settings, including at retail, mail order and as a pharmacy benefits manager. 

Our Focus on Safe, Clinically Appropriate Therapy

As a provider of prescription drug benefits for nearly 90 million members, we have developed processes aimed at delivering the highest level of patient care and safety to our members. We are proud of our pharmacy teams’ dedication to ensuring that each patient’s care is closely monitored and coordinated with his or her physician.

This includes making major investments in technology and training to ensure that the right person receives the right drug at the right time. Our teams review each prescription to ensure prescriptions are safe and clinically appropriate before they are dispensed, using point-of-service prescriber and patient verifications, along with drug utilization reviews at mail and retail pharmacy locations. We also engage in regular dialogue with prescribers and members, and follow clinical guidelines to identify situations that may contribute to prescription misuse or abuse.

Utilization Management: An Evidence-Based Approach

As we develop our review processes, we take expert recommendations into account to align our guidelines with clinical evidence, such as:

  • Opioid prescribing guidelines from the Centers of Disease Control

  • Labeling requirements set by the Food and Drug Administration

  • Guidance from the U.S. Surgeon General

These resources inform our evidence-based approach to utilization management, which we have designed to monitor safe prescription drug use, promote optimal health outcomes and deliver the most cost-effective care. This process includes:

  • Reviewing  a patient’s diagnosis to identify if an opioid prescription is appropriate;

  • Evaluating contraindications with other medications the patient is taking; and

  • In some cases, identifying other medications the patient should try first, based on clinical criteria. 

This process can be beneficial because patients and physicians may be unaware of potential red flags, including drug-to-drug interactions, contraindications, overdosage, therapeutic duplications and age inappropriateness. 

Safety at Mail Service and Beyond

At our mail service pharmacies, we have a dedicated team of pharmacists who review all of the schedule II controlled substances we fill. These pharmacists often become familiar with members, their health situation, medical needs and other health care providers, so they can closely monitor how members’ medications are contributing to their overall care plan. The pharmacist team specializes in all aspects of controlled substance medications, ensuring our pharmacists have the expertise to know when to reach out to the prescriber if there is a concern.

In addition to our focus on the safety of medications we dispense at our mail service pharmacies, we also work to ensure that the care of all of our PBM members meets the highest clinical and safety standards no matter where they fill their prescriptions. 

For example, we have access to advanced data analytics to review all of a member’s prescriptions, even if they are filled at more than one pharmacy. In the case of controlled substances, this review can help us identify instances where our pharmacists may need to take a closer look at the patient’s clinical situation. These pharmacists can then contact the patient’s physician and pharmacy to coordinate care. 

While our patients’ health and safety are of paramount concern, our efforts are also helping to curb unnecessary medical costs. We estimate that our patient safety efforts saved more than $100 million in 2015, including $74.3 million in unnecessary pharmacy spending and $26.1 million in other avoidable medical costs.

For more information about CVS Health’s efforts to address prescription opioid abuse and misuse, visit our Prescription Drug Abuse information center.