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U. BlueShield
Association
The Blue Cross and
Blue Shield System’s
Commitment to Fighting
Opioid Use Disorder
O
pioid misuse in the United States has escalated into a deadly epidemic. According to the Centers for
Disease Control and Prevention, prescription painkillers and heroin are claiming the lives of 91
Americans every day. What often starts as treatment for pain too frequently ends in an opioid use disorder,
leading to the largest rise in heroin use in over 20 years and costing more than $78.5 billion annually in direct
healthcare costs.
Blue Cross and Blue Shield (BCBS) companies, with more than 106 million members and deep ties to every
local community in America, are uniquely positioned to help raise awareness and find solutions to this
serious problem that is lurking inside medicine cabinets across the country.
NATIONAL INITIATIVES
The Blue Cross Blue Shield Association (BCBSA) and member BCBS companies are committed to
addressing the nation’s growing opioid crisis community by community, nationwide. As part of this
commitment, the BCBS System has a number of initiatives underway, including:
Increasing awareness and education of the risks associated with opioid use through the funding
and production of public education programs.
Leveraging the BCBS System’s industry-leading data capabilities to uncover deeper insights
into the prevalence of opioid use disorder in the U.S. and collaborating with leading research
institutions to develop a framework for improving the treatment of opioid use disorder.
Investing in research by convening scientists, academic researchers and clinical experts to develop
and implement protocols to successfully reduce rates of relapse.
Promoting best practices by convening an executive-level committee of top BCBS System experts
in pharmacology, psychology, behavioral health, policy, strategy and business to coordinate
systemwide efforts for the successful treatment of patients suffering from opioid use disorder.
Blue Cross Blue Shield Association is an association of independent Blue Cross and Blue Shield companies.
Local Blue Cross and Blue Shield Company Initiatives (Alphabetical Order)
BCBS companies around the country are already undertaking initiatives to help families and communities
address the opioid epidemic. Examples include:
Anthem, Inc.
Anthem is setting aggressive goals to help prevent opioid use disorder and increase access to care –
including doubling the number of members getting counseling and reducing the total amount of opioids
dispensed among health plan members by 30 percent from historic peak levels by the end of 2019.
Anthem continues to expand and refine a comprehensive suite of services to assist members and their
physicians in managing opioid use disorder. Opioid and substance use disorders (SUDs) are chronic disease
conditions, best treated and managed through a holistic and personal approach to care. Addressing both
prescription opioid management and the early identification and treatment of opioid use disorder are
fundamental objectives of Anthem’s strategy. Anthem seeks to do this through a combination of enterprise-
wide initiatives with a focus on local needs and collaborating with local services and providers.
Anthem operates Pharmacy Home programs in its Medicaid and commercial business to encourage
appropriate prescription opioid use for high risk members. With this program, members receive prescriptions
from one provider and fill prescriptions at one pharmacy. In order to facilitate early identification and
treatment for opioid misuse, Anthem is working directly with primary care physicians in rural areas to extend
availability of medication assisted treatment. Anthem provides a variety of care management programs that
encompass a wide range of approaches to coordinate care and assist members after medication assisted
withdrawal as well as with recovery and long-term stability. Finally, Anthem has enhanced screening and
case management for substance use disorders for maternal and child health members.
Blue Cross and Blue Shield of Louisiana
In 2015, BCBS of Louisiana partnered with the National Association of Drug Diversion Investigators to
install 29 drug take-back boxes around the state. The drug take-back boxes are located in Louisiana law
enforcement agencies, and each month, the contents are properly disposed of. In just a short time, the
program is making a big impact with one Sheriff’s office reporting it has already collected more than 2,500
pounds of pills since September 2015. The program is planning to expand and add to the number of drug
take-back boxes available. In addition, BCBS of Louisiana has been supporting the U.S. Drug Enforcement
Administration’s National Prescription Drug Take-Back Day since 2011.
Blue Cross and Blue Shield of Massachusetts
The misuse of prescription painkillers is a safety and healthcare quality priority for BCBS Massachusetts.
The company has put into place a Prescription Pain Medication Safety Program that implements opioid-
prescribing best practices. It includes an agreement between the patient and prescriber outlining
responsibilities and behaviors of both sides, an assessment of addiction risk, the use of a single pharmacy or
pharmacy chain for opioid prescriptions and prior authorization for all new short-acting prescriptions
exceeding a 30-day supply. It also ensures doctors are informed about narcotic prescriptions their patients
receive from other providers and provides members access to the care they need. The terminally ill and
cancer patients, for example, are not included in the program. A Centers for Disease Control and Prevention
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(CDC) study has praised the program finding that it has lowered the average monthly rate of opioid
prescriptions by 15 percent and reduced the number of members using opioids by up to nine percent. In
short, Blue Cross and Blue Shield of Massachusetts’ Prescription Pain Medication Safety Program has
reduced the risk of addiction and misuse of prescription painkillers while protecting vulnerable patients.
Blue Cross Blue Shield of Michigan
The BCBSM Doctor Shopper program addresses the issue of members who obtain controlled substances
from multiple providers without the prescribers’ knowledge of other prescriptions. The goal of the program is
to reduce the number of members who misuse their prescription drug benefit, reduce the risk of opioid
overdose and to improve coordination of care among physicians.
Through the Prescriber Block Program, BCBSM/Blue Care Network implemented a claims edit to block
prescriptions written by practitioners who prescribe drugs that:
– Are not medically necessary
– May cause significant patient harm
– Are not appropriate for the documented medical condition
Adverse drug interactions may result in patient suffering, costly and avoidable medical care, or even death.
The "Holy Trinity" is a drug regimen consisting typically of an opioid analgesic, a benzodiazepine and Soma®
(carisoprodol). This combination of controlled substances has no legitimate medical indication according to
physician experts. The Holy Trinity Initiative, which began in August 2014, continues to educate providers
about this deadly combination and coordinate care for BCBSM/ Blue Care Network members who obtain
these medications from multiple prescribers. Prescribers who wrote at least one prescription for members
who received this drug combination receive a letter in the mail.
Electronic prescribing of controlled substances improves patient safety, increases efficiencies and reduces
fraud, waste and abuse. The goal of the Controlled Substances Electronic Prescribing Program is to
increase controlled substance e-prescribing rates. Over 40 physician organizations receive quarterly
feedback reports showing the mode by which their attributed physician’s prescriptions were transmitted (i.e.,
written, facsimile, phone and electronic) for both retail and mail order prescriptions. The reports help them
track their e-prescribing performance and identify opportunities for improvement. Physician organizations
receive rewards for improving their average performance in Electronic prescribing of controlled substances.
Blue Cross & Blue Shield of Rhode Island
Blue Cross & Blue Shield of Rhode Island supports Rhode Island Department of Health initiatives to
minimize exposure to opioids by limiting the number of opioid doses prescribed to patients who are first time
users. BCBSRI’s requirement for prior-authorization for long acting opioid prescriptions led to a 25 percent
reduction in such prescriptions in 2014. BCBSRI has removed prior-authorization requirements for the first
10-day prescription of Suboxone
®
, making it easier to address recovery needs immediately. BCBSRI also
provides members with access to peer recovery coaches.
BCBSRI also covers services through Butler Hospital’s ambulatory detoxification program for members who
are able to travel back and forth from home, have home-based support and do not have medical or
psychiatric conditions that require an inpatient level of care.
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In 2016 BCBSRI implemented the CODAC Medication Assisted Treatment Program to increase access to
intensive medical treatment options addressing opioid use disorder. CODAC, deemed Rhode Island’s first
Center of Excellence by state health officials for its treatment of opioid use disorders, provides treatment,
recovery and prevention services to individuals and families. As part of the CODAC program available to
BCBSRI members, individuals receive a comprehensive biopsychosocial assessment and medical exam
prior to being treated for opioid use disorder. Members also have expanded treatment offerings, including
methadone, Suboxone
®
and others. Ongoing support and interventions to maintain recovery are a critical
part of the program.
BlueCross BlueShield of South Carolina
BlueCross BlueShield of South Carolina is in the early stages of an innovative pharmacy campaign which is
designed to reduce overdose deaths from opioids and other controlled substances and increase access to
substance use disorder resources and treatment options. The initial efforts focus on a widespread provider
education outreach that encourages safe prescribing practices and access to health coaching services for
those patients/members with addiction issues. In addition, cross-functional teams of behavioral health
professionals, medical directors (psychiatrists) and others within the organization work together to identify
providers who are writing large numbers of these prescriptions. Providers are called and invited to speak to
BlueCross BlueShield of South Carolina medical directors about their practice experience. Early feedback
indicates that these peer-to-peer conversations are welcomed by the provider community. We anticipate
widespread adoption of these offerings.
BlueCross BlueShield of Tennessee
The BlueCross BlueShield of Tennessee Health Foundation has partnered with the state Department of
Health and the Coffee County Anti-Drug Coalition to reduce prescription pain medication misuse and abuse
via the Count It! Lock It! Drop It! (CLD) program.
Founded in 2011, CLD encourages community members to:
– Count pills once every two weeks to monitor theft and help ensure medications are taken properly.
– Lock and store medications in a secure place where others would not think to look.
– Take unused or expired medications to drop boxes located in participating law enforcement offices or
pharmacies or during take-back events.
CLD’s grassroots programming, currently represented in 33 Tennessee counties, includes education
outreach and promotion of safe disposal sites. In 2016, the BlueCross BlueShield of Tennessee Health
Foundation granted $1.3 million to fund CLD’s expansion to areas identified as “hot spots,” which are
counties with high numbers of opioid prescriptions dispensed, overdose deaths and babies born with
neonatal abstinence syndrome. The funding also supports a statewide public awareness campaign driven by
public service announcements and other awareness-building efforts.
The BlueCross BlueShield of Tennessee Health Foundation also partnered with the University of
Tennessee’s Law Enforcement Innovation Center (LEIC) to train law enforcement professionals on how to
administer Naloxone, a lifesaving anti-opioid-overdose medication and funded a $250,000 grant to help law
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enforcement organizations obtain the treatment.
The Foundation continues support of the Mothers and Infants Sober Together (MIST) program, which
provides a variety of behavioral health services to pregnant women and mothers with drug-exposed infants.
BlueCross BlueShield of Vermont
BCBSVT’s fights opioid use disorder and opioid-related deaths in Vermont through innovative initiatives, key
partnerships, insightful prescription policies and community outreach. BCBSVT sets quantity limits and
prior authorization requirements for pain medications and modifies benefits to reduce barriers to care—
for example by eliminating every-visit co-payments for daily substance use disorder treatment. The
organization supports drug disposal days, identifies inappropriate opiate sourcing from prescribers and
pharmacies and participates in a fraud detection consortium to identify problematic prescribing. BCBSVT
provides training
on nationally established Screening, Brief Intervention and Referral to Treatment (SBIRT) methods and
structures its reimbursement design to support substance use disorder treatment in primary care settings.
BCBSVT’s psychiatrist medical director also provides care, consultation and education to Vermont
communities. In addition to its clinical efforts, BCBSVT concentrates its community outreach efforts on
addiction, and particularly opiate use. The company partnered with neighboring Kingdom County Productions
on two award-winning documentaries that sparked conversation about Vermonters affected by drug use.
These documentaries toured the state flanked by their producer and the addicts who shared their stories
in the movies. After each showing, Vermonters engaged in lively, often poignant, conversations about
opioid use in their communities.
BlueCross BlueShield of Western New York
The region's largest health plan has taken a leadership role in fighting the epidemic since launching a
community-wide public awareness effort in 2013 called “PainKillers Kill.” The initiative focuses on providing
resources to the medical community and community-at-large and includes middle and high school
curriculum, a documentary, multi-media advertising, information cards for pharmacies and doctors’ offices, a
dedicated website and a 24/7 hotline. After the initial launch of the campaign, over 1 in 3 consumers reported
taking action inspired by the campaign, most often by discussing addiction with friends and family or
discarding expired medications.
In 2017, BlueCross BlueShield of WNY is funding a new program called “House of Hope” which educates
and involves families with the recovery process of their loved one suffering with addiction. By educating
families and providing access to volunteer recovery coaches and drug treatment professionals, the program
provides suffering individuals with a better support system at home.
The goal is to reduce the current 92 percent relapse rate within the first 6 months after completing treatment.
Additionally, the health plan has made significant policy changes including removing preauthorization for all
medically assisted therapies, reducing first-fill opioid prescriptions to seven days, creating a behavioral
health advisory committee with local mental health providers and community leaders, and developing a
robust care management program to help members find care within a recommended treatment plan.
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Blue Shield of California
Blue Shield of California launched a three-year Narcotic Safety Initiative to help reduce inappropriate
prescribing and overuse of opioid narcotic medications. Since opioids are not very effective for chronic non-
cancer pain – in fact, may actually worsen pain – and lead to drug dependence, the company is working to
reduce the number of people on chronically high doses of opioids; reduce the number of people converting
from short- to long-term opioid use; and reduce the prescription quantity and number of refills prescribed
for people newly starting opioids. Blue Shield has enhanced medication coverage policies and formulary
management; engaged providers to practice prudent prescribing and create care plans that include tapering
and stopping opioid use; and developed an interdisciplinary case management program that addresses
quality, fraud, waste or abuse. Additional programs to manage chronic pain, addiction and substance use
disorder will also be launched. In the first year, the program has resulted in a reduction in the use of
narcotics, particularly people on high doses.
Capital BlueCross
Over the last two years, Capital BlueCross has committed a total of $150,000 to help fight heroin addiction
in central Pennsylvania and the Lehigh Valley. The funding enables the purchase of naloxone for municipal
police departments in its service area. The prescription drug can help save the life of a person who has
overdosed on prescription painkillers or heroin.
Excellus BlueCross Blue Shield
Like many other places across the country, the number of opioid-related deaths and overdoses remains
frighteningly high in upstate New York. As one way of combatting this epidemic, Excellus BCBS expanded
an initiative that was originally implemented in May 2016 that now includes an auto-approval of initial lengths
of stay of 5 days for inpatient opioid detoxification, 14 days for opioid inpatient rehabilitation and 14 days for
opioid residential treatment in NY-licensed facilities for eligible members. For medical necessity reviews for
additional days after the auto-approved initial length of stay, Excellus BCBS is changing to Level of Care for
Alcohol and Drug Treatment Referral (LOCADTR), the review criteria adopted by the New York State Office
of Alcoholism and Substance Abuse Services, which helps determine the most appropriate recommended
level of care for individuals.
Excellus BCBS has been a long-time supporter of buprenorphine treatment and provides an incentive for
induction visits. Excellus BCBS developed a unique partnership of payer, providers and regulators called the
WNY Collaborative ECHO for Chronic Pain, Opioid Prescription, Substance Use Disorder and Medication
Assisted Treatment. This partnership brings virtual case conferencing on pain and addiction to primary care
providers.
Excellus BCBS is also working with physicians to promote better care that follows recommendations from
Choosing Wisely, an initiative of the American Board of Internal Medicine Foundation. The initiative’s goals
are to improve the quality of care and encourage physician-patient conversations about services that may be
unnecessary and may cause harm.
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••
Florida Blue
Florida Blue has implemented a comprehensive management program, following guidance from the Centers
for Disease Control and Prevention, to address opioid use disorder in Florida. Focusing on safety first,
known opioid best management practices were implemented which includes providing a host of services for
providers and members. The company’s programs include the use of physician/member treatment
agreements, analytics to identify “doctor shopping” and narcotic diversion, along with limiting day supply and
ensuring appropriate utilization and dosing through medical coverage policies. In addition, Florida Blue
requires both providers and pharmacies to utilize the state’s Prescription Drug Monitoring Program (PDMP)
before writing and dispensing opioid prescriptions. The company retrospectively reviews controlled
substance claims, consults with prescribers and members by phone about narcotic use, refers members to
pain and/or behavioral health specialists when appropriate, conducts regular pharmacy audits, provides
prescribers with education and limits members to one prescriber and one pharmacy or pharmacy chain when
appropriate. Florida Blue’s program has yielded a reduction in controlled substance claims, and providers
have reacted positively.
Health Care Service Corporation (HCSC)
HCSC, which operates Blue Cross and Blue Shield companies in Illinois, Montana, New Mexico, Oklahoma
and Texas, applies a multi-pronged approach to manage controlled substances. HCSC’s Controlled Drug
Substance (CDS) program identifies opportunities to help improve member care by monitoring pharmacy
claims data for the potential misuse of controlled substances. An informational letter is sent to the prescriber
to help reassess the member’s treatment regimen. The company’s comprehensive Controlled Substance
Integration (CSI) program is designed to identify patterns of atypical controlled substance usage and
intervene in cases of suspected misuse, abuse, opportunities for care coordination, patient or provider
management and/or education. The CSI Provider-Centric program reviews opioid prescribing patterns
among certain prescribers and engages them in opportunities and provides resources to support their
management of HCSC members.
HCSC also engages in collaborative efforts to manage fraud, waste and abuse (FWA). The Special
Investigations Department (SID) provides fraud detection, investigation and prevention services that can
include law enforcement and the pharmacy audit division. Comprehensive pharmacy audit and education
programs further promote these collaborative FWA efforts. Utilization management and drug utilization
review activities also allow for monitoring of potential drug therapy problems before dispensing.
Highmark, Inc.
Highmark Inc., which operates Blue Cross Blue Shield companies in Pennsylvania, West Virginia and
Delaware, has taken a number of strategic measures to address the opioid epidemic. Highmark is working
with providers to give them the resources and tools that support appropriate prescribing protocols. The
quality improvement program uses claims data to help physicians better understand their patients’ total
prescription and medication use and gain insight into their own prescribing patterns. Another program aims
to detect patients who might be addicted to opioid pain pills by limiting them to using only one pharmacy
when filling prescriptions for controlled substances. Other initiatives include the addition of pharmacists to its
care management team to help members who have multiple health issues manage their prescription
medications safely and effectively and a $75,000 contribution to provide naloxone to local law enforcement
officials across Pennsylvania to fight the opioid overdose epidemic. Additionally, the Highmark Foundation
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hosted a solutions-based forum to bring together thought leaders and industry experts in West Virginia to
explore ways to reduce the impact of opioid use disorder and donated $50,000 to assist police departments
in western Pennsylvania with the purchase of naloxone kits to reduce the incidence of opioid overdoses.
Highmark continues to work with state officials and other community stakeholders to tackle this public health
crisis.
Horizon Blue Cross Blue Shield of New Jersey
In addition to traditional, member-focused opioid management programs, Horizon BCBSNJ, in collaboration
with Principled Strategies, developed the SafeUseNow
SM
Opioid Management Program. This program is an
educational, prescriber-centric intervention designed to stop prescription drug abuse and encourage safe use
of opioids for patients. To increase the safe use prescribing of medications, the SafeUseNow program
identifies combinations of prescribers, patients and pharmacies at risk for medicine misuse and suggests
action steps to take both within and external to the Horizon BCBSNJ network. Phase 1 and Phase 2 of the
educational intervention program collectively delivered comprehensive, fact-based and actionable risk
reports to 1,700 prescribers treating 60,000 patients. To date, results have achieved statistically significant
reductions in key endpoints, including Concomitance and Morphine-Equivalent Dose (MED), PSI Score™,
Multiple Prescribers and Multiple Pharmacies, resulting in a reduction in annualized direct pharmacy costs of
$2.6 million. Phase 2 results are forthcoming.
Independence Blue Cross
Independence addresses the crisis of prescription opioid use disorder on multiple fronts and believes that all
stakeholders need to play a constructive role in finding thoughtful solutions. Independence has a strong
focus on reducing inappropriate prescribing by:
– Implementing enhanced preauthorization requirements for high-potency opioid narcotics;
– Working with CMS to identify Medicare members trying to obtain prescriptions from multiple sources and
reporting that information to prescribing physicians;
– Educating doctors directly and through the company’s online provider resources on new opioid
prescribing guidelines; and
– Conducting outreach to doctors who do not follow critical aspects of the Centers for Disease Control and
Prevention’s guidelines for non-cancer pain, alerting them to their outlier prescribing status.
Independence provides online tools that allow its members and the public to more easily access information
on opioid safety, drug disposal and addiction resources. Independence has expanded prescription coverage
of the overdose reversal drug Naloxone to include a nasal spray that produces a faster response and has
donated $50,000 to the District Attorneys Association of Pennsylvania for the purchase of Naloxone for law
enforcement officers in Southeastern Pennsylvania.
In addition, the Independence Blue Cross Foundation's STOP (Supporting Treatment and Overdose
Prevention) initiative increases awareness and access to effective community-based opioid treatment and
prevention. STOP will expand outcome-and evidence-based programs and community resources, identify
the barriers to treatment and prevention, and disseminate effective community-based strategies and
education around this public health epidemic.
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