What Can Insurers Do?

Mitchell Opioid prescribing guideMost payors rely on PBMs to assist in managing opioid prescriptions through network discounts as well as clinical management. Opioid guidelines, whether from the CDC or other agencies and organizations, help to ensure injured worker safety, promote better outcomes, and lower overall claims cost. As opioid guidelines become more enforceable over time (through industry adoption or legislation), PBMs need to have dynamic pharmacy claims management systems, earlier visibility into medications prescribed for the claimant, and comprehensive insight into all injury related prescriptions for the injured worker.

Step 1: Plan for Success

Craft the Right Formulary

Before any worker is ever injured, insurers have the opportunity to set up their programs for success. The first step is to create robust, injury-specific, dynamic formularies that take the CDC Opioid Guidelines and/or additional regulations into account. Doing so will help both the PBM and the adjustor make the best decision at critical points in the claim.

Mitchell managed care solutionsIntegrate Managed Care Best Practices Into Your Program

Managed care is a critical component of an insurers’ opioid management strategy. Insurers have the opportunity to craft a plan that includes best-practices such as early-claim education programs for families and claimants as well as integration with the claims process so all recommendations are fed back into the decision making on a claim.

Additionally, managed care triggers should be set up based on risk alerts to quickly get claimants the support they need. Triggers could result in actions such as a pharmacist review based on drug combinations or a peer-to-peer conversation based on prescribing behavior. Managed care for opioid use should also include plans for how best to support those claimants who have become addicted to opioids during their recovery.

Step 2: Identify Challenges and Opportunities with Partners

The CDC Opioid Guidelines (as well as other guidelines) defines limits to the duration of the first opioid prescription, recommends that immediate release formulations be used, and places limits on the dosing of opioid prescriptions. Therefore, to support insurer adoption of such guidelines, PBM claims management systems must recognize the first opioid prescription and ensure that the prescription meets these dosing, duration, and formulation requirements. The system must then be flexible enough to adjust to subsequent prescriptions as changes in the claim occur.

Challenge: First Opioid Fill Visibility Mitchell PBM visability

Specifically, the CDC Opioid Guidelines place recommendations on the first opioid prescription. This is a challenge for many PBMs as they do not always have visibility into the first prescription filled post-injury. These prescriptions are frequently obtained even before a claim has been reported to the insurer.

Having visibility into these ‘first fills’ is essential in enforcing appropriate opioid management in accordance to prescribing guidelines. Insurers can work with their PBM to ensure that first-fills are being captured by identifying their leakage and then establish programs to acquire those first fills of opioids as well as manage them with clinical controls such as blocks and prior authorizations.


Challenge: Total MED Visibility MED calculator

Additionally, to evaluate the total daily dose of opioids prescribed, the PBM must have full visibility into all prescriptions the claimant is receiving. This is another challenge for many PBMs as they do not typically capture all prescriptions. Prescriptions may not be visible to a PBM because they were not

identified at the point-of-sale and subsequently paper billed by the pharmacy. This circumvents the controls at the point-of-sale and makes it difficult to re-capture that prescription data into the system.

In the event that prescriptions are unaccounted for, the MME/day calculation will be understated. This may lead to an underestimation of risk and missed opportunities to identify and intervene on claims that do not comply with opioid prescribing guidelines. Insurers can support this improved visibility across the claim by integrating bill review and PBM systems to have a universal view of all the prescriptions a claimant is receiving. Only then, can the PBM make accurate risk assessments to keep the claim in compliance and avoid harm.


In a country facing a major epidemic of opioid addiction, the workers’ compensation industry has a role to play. It is in a unique position to continue to take the best-practice recommendations, such as the CDC Opioid Guidelines, to craft programs that support claimant health during and after injury recovery. While it is clear from the data that many of these recommendations are already happening today, a percentage of claimants are still at risk of becoming addicted to the very medicine designed to help them. Therefore, it is critical that insurers both build the right programs and partner with solution providers to correctly identify and support claimants who may be at risk.

By selecting a PBM partner with the ability to plan for success as well as have the technology and solution capabilities to manage the complexities of prescribing guidelines, insurers and their claimants can achieve measurably better outcomes.



Posted in: Case Studies & White Papers, Workers' Compensation Management, Pharmacy Solutions

Terms of Use | Privacy Practices | Copyright & Usage | [+} Report a Problem
© 2021 Mitchell International, Inc. All Rights Reserved.
By accessing Mitchell.com, each user agrees that they have read and agreed to be bound by the
Terms and Conditions governing Mitchell.com and Privacy Policies governing Mitchell.com.