Opioid Support

Chronic pain is a common public health problem. Treating patients with chronic pain involves a thoughtful balance of providing adequate pain relief and avoiding adverse side effects. It also requires monitoring for opioid use disorder, fraud, waste and abuse.

According to the Centers for Disease Control and Prevention, in 2019 there were nearly five opioid prescriptions dispensed for every ten people. In some counties in the U.S., the rates were six times higher than that.

CareFirst has developed a holistic approach to combat the opioid epidemic through various strategies, including prevention, treatment options, and support and outreach.

As a clinician, you can help reduce opioid misuse and addiction through ongoing communication, engagement and assisting patients to better understand their opioid medications, risks and alternative therapies.

CareFirst has implemented select utilization management strategies on opioid prescriptions to help ensure safe and appropriate use. These strategies are based on the Centers for Disease Control and Prevention’s Guidelines for Prescribing Opioids for Chronic Pain.

Current opioid utilization management strategies are summarized in the chart below.

Utilization Management	Product Type	Description
Duration Limit	Immediate-Release Opioid Products (new users)	Coverage for initial opioid prescriptions is limited: Up to a 7-day supply for members 20 years of age and older Up to a 3-day supply for members 19 years and younger AND Opioid prescriptions are limited to a maximum 14 days of therapy in a 90-day period.
Quantity Limit	Extended-Release and Immediate-Release Opioid Products (new and existing users)	Coverage for up to 90 MME per day
Step Therapy	Extended-Release Opioid Products (new users)	Coverage for an immediate-release product must be utilized for greater than 14 days before an extended-release product will be covered.

Medical Necessity

If an opioid prescription above 90 MME, or more than 14 days of therapy is medically necessary for a member, a provider may submit a prior authorization. Prior authorization approvals have a post-limit quantity limit of up to 200 MME per day and duration limit of up to a 30-day supply.

Results since implementing our utilization management strategies:

• 80% reduction in first fill for short-acting opioids with greater than a 7-day supply
• 45% reduction in opioid prescriptions filled
• 26% reduction in average MME/prescription filled

Safety and Monitoring Program

CareFirst’s Safety and Monitoring Solution Program supports drug safety. It identifies potential fraud, waste and abuse of controlled substances, such as opioids, benzodiazepines and muscle relaxants.

Our clinical pharmacists:

• Identify misuse or overuse of controlled substances,
• Collaborate with clinicians and case managers to adjust medication therapies, and
• Coordinate care appropriately.

Combining our evidence-based decisions with clinical attention can highlight areas of potential concern and drastically impact dangerous use patterns.

Members with multiple prescriptions, prescribers and pharmacies are reviewed by a pharmacist who determines if prescriber outreach is necessary for member intervention. The most severe cases are sent to CareFirst’s clinical pharmacy services team to further review and decide the next steps for appropriate interventions.

Effective recovery programs recognize that addiction is not a personal failure but a chronic disease requiring long-term treatment options.

Through comprehensive training programs, CareFirst is educating primary care providers, nurses and behavioral health providers about our behavioral health and substance use disorder resources.

Locally, CareFirst is working with high-performing recovery centers, leaders in intensive outpatient programs (IOPs). These centers provide highly individualized treatment, including relapse prevention, coping strategies and evidence-based Medication-Assisted Therapy (MAT).

CareFirst is taking additional steps to connect members to essential treatment, including:

• Making same-day appointments available to our members by building a referral database of authorized MAT providers.
• Educating members about the specialized assessment team and local recovery centers.
• Highlighting our Blue Distinction Centers for Substance Use Treatment and Recovery program to employers to help employees get the help they need. This program offers access to more than 250 nationally accredited treatment facilities.
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To help support your chronic pain treatment recommendations and care plans, CareFirst has created several resources for you. We encourage you to share them with your patients to assist them with their pain management. 

• View a list of specialist partners for pain and care management.
  Pain Management Support Centers
• Explore a comprehensive list of opioid treatment centers, programs, partners and services.
  Opioid Treatment Resource Guide

If your patients would like additional information on pain management, opioids and support, please feel free to share our member website with them—carefirst.com/opioidsupport.

As part of CareFirst’s ongoing commitment to serving the needs of our provider partners, our Learning and Engagement Center website offers a variety of educational opportunities tailored to your needs, including:

• Monthly webinars
• Half-day seminars
• Online learning modules
• CareFirst Direct hands-on training sessions