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Insurance Companies Respond to Opioid Epidemic Insurance

According to a September 2016 study published in Medical Care Magazine, the total annual cost of the U.S. opioid epidemic is $78.5 billion, most of which is attributed to insurance coverage. 1 The impact of this crisis is having a significant effect on benefit claim costs and more so on overall productivity of the private employer workplace. With this in mind, this document outlines the posture and reformative contractual changes being taken by insurers in the health insurance industry.

We then highlight strategies in the fight against opioid addiction, more generally. These efforts include the changes being made to prescribing methods and prescription drug monitoring, respectively. We hope the information provided will help to both educate and assist you in developing strategies to further the wellbeing of your employees and your organization. The following is a summary of the major carriers’ stances on opioid addiction to date.


In October of 2016, Cigna became the first insurance company to reevaluate the efficacy of prior authorization in prescribing of anti-opioid addiction medications. The company eventually removed these barriers. Cigna's pioneering efforts drew high praise from addiction specialists nationwide and have caused two other major insurance companies to follow suit. Additionally, Cigna has committed to reducing the number of opioids prescribed to their own members by 25% over the next three years. If this reduction is achieved, it would return the amount of dispensed pain killers to 2006 levels, prior to the opioid epidemic becoming a national crisis. 2

Cigna, like other companies, has promised to improve access to medication-assisted therapy. This would provide counseling to opioid-addicted patients in conjunction with prescribed drugs like Suboxone that help to alleviate the symptoms of opioid withdrawal and decrease the chances of accidental overdose. Cigna believes that this initiative will eliminate the stigma attached to substance abuse and result in greater numbers of affected people seeking the treatment they need.

Anthem Blue Cross Blue Shield

In January of 2017, Anthem became the second major insurance carrier to remove the prior authorization requirement in the prescribing efforts of oral buprenorphine (Suboxone). This effort was intended to increase access to proven methods of addiction treatment. In addition, Anthem began to implement stricter quantity limits on opioid prescriptions with the intent of preventing patient dependence on their medication.

Per their most recent press release, Anthem has expressed a dedicated commitment to improving the number of patients receiving behavioral healthcare in the treatment of opioid addiction. Specifically, Anthem projects to double the number of members who receive behavioral counseling as part of a medication-assisted therapy (MAT) for addiction to opiates. 3 In conjunction with this goal, Anthem aims to reduce the number of prescribed opioids by 30% by the end of 2019. The company is actively working to connect non-psychiatric doctors to behavioral health services to ensure that counseling is administered as patients undergo their drug therapy. By early 2018, Anthem will have these behavioral initiatives included in all affiliated health plan states.


In February of this year, Aetna became the third major carrier after Cigna and Anthem to remove the prior authorization barrier for members trying to obtain medication for treatment of an opioid addiction. This change in policy, which became effective in March of 2017, only applies to commercial health plans. However, it will provide improved access to necessary care for the majority of their policyholders. Aetna members battling addiction will now be able to receive prescriptions directly from their doctors for drugs like Suboxone that alleviate the symptoms of opioid withdrawal. The company states that these drugs are intended to be prescribed in combination with a dedicated regimen of drug abuse counseling. 4

In order to monitor opioid abuse trends, Aetna has also created a Special Investigation Unit whose sole purpose is to pinpoint members who may be abusing their prescriptions. Once an individual has received four or more prescriptions for controlled substances within the opioid class, the member's provider(s) and pharmacy(s) are immediately notified of the potential problem.

United Healthcare

UHC has committed to undertake a retrospective approach to curbing the opioid epidemic. Their ultimate goal is to change prescribing trends as they apply to non-evidence based opioid medications and shift addiction care to behavioral interventions.5 Unlike the three companies discussed above, United Healthcare has maintained prior authorization requirements aimed at restricting abuse of opioid medications like Suboxone. However, they do not require prior authorization for Narcan - a prescription medication that reverses the effects of opiates in an emergency overdose situation.

UHC is utilizing predictive modeling and pharmacy claim reviews to identify opioid dependence. Since 2007, their Retrospective Narcotic Overutilization Program has identified members who are at higher risk of addiction due to multiple opioid prescriptions received from more than one doctor or pharmacy. Once these individuals are identified, their healthcare and pharmacy providers are notified. To further support members battling an opioid dependence, UHC provides open access to a 24/7 Substance Use Treatment Hotline staffed by licensed mental health professionals.

We hope this information proves helpful in discussing this critically important trend unfortunately occurring across the country. The following addendum outlines additional strategies for consideration. We would be happy to discuss any of these reformative initiatives in more detail.


Tackling a nationwide epidemic requires a multi-faceted, coordinated effort from all stakeholders including providers, employers, employees, pharmacy benefit managers (PBM) and insurance carriers supporting healthcare. This addendum highlights monitoring steps being considered and/or utilized by healthcare providers and insurance carriers to limit the abuse of prescribed opioid medications.

Prescription Drug Monitoring

Insurance companies and healthcare providers have begun to work in tandem to identify and monitor individuals with confirmed and suspected opioid abuse patterns. Below is a list of these monitoring steps:

Removing Prior Authorization Requirements

When anti-opioid addiction medications were initially made available through doctors' offices, the health insurance companies established prior authorization requirements before patients could receive their prescriptions. At first, this effort was viewed as a control measure for prescribing drugs that might pose a risk to the patient. Advocates stated that it was an added step to ensure that the correct treatment was being provided. Now, however, the insurance companies are beginning to reevaluate, and in some cases, remove the prior authorization requirement altogether on these drugs.

Critics of prior authorization say that it hinders people's ability to overcome their addiction.Addiction treatment specialists argue that a delay of even a day or two can be critical. In October 2016, Cigna was the first major insurance company to remove the prior authorization requirement for addiction treatments. Since then, Anthem and Aetna have followed suit. They no longer require patients with a record of opioid use to be approved before receiving care for a possible addiction.

Predictive Modeling

Hundreds of thousands of medical claims pour in from the millions of insured U.S. policyholders each day. It is a tedious task to mine through all the data, much less monitor it for behavioral trends. Despite the difficulties, health insurance providers have begun to use predictive modeling to identify at-risk policyholders to prevent drug misuse and addiction. One major health insurance company reported the analysis of six million opioid pharmacy claims in 2015 filed by two million policyholders who may be at risk for opioid dependence! 5

The insurance companies look for clear indicators to flag an individual as an at-risk member. The most blatant of these indicators is a filed claim for Narcan. Once claims adjusters are aware of a policyholder being prescribed this counteractant, they know that the individual has either had an opioid overdose or is taking enough pain killers that an overdose is a real possibility. In either case, it indicates that the policyholder has a pattern of frequent opioid use, and most likely, dependence.

These drug utilization review initiatives are intended to both categorize and change prescribing behaviors. All major insurance companies have begun to review their quantity limits to capture data on every opioid prescription written for an individual, not just a single prescription. Then, they coordinate directly with the individual’s healthcare provider to alert them to patients who may be abusing their opioid medications.

Single Pharmacy Access

Drug utilization reviews and predictive modeling efforts have uncovered policyholders who abuse their opioid prescriptions by accessing care from multiple doctors and/or pharmacies. When people become addicted to their pain medication, the normal 30-day prescription no longer adequately feeds their dependence. So, they attempt to circumvent the normal prescribing methods to double-dip and receive additional medication. These opioid abusers may have been able to beat the system in years past. But today, health insurance providers are cracking down to prohibit this practice at all costs.

On July 1st, 2012, Blue Cross Blue Shield of Massachusetts implemented their landmark opioid utilization program. This program was initiated because of a prescription data analysis that identified many policyholders who were receiving brand new opioid prescriptions with a greater than 30-day supply. Under the program guidelines, patients receiving opioid prescriptions are required to sign a drug abuse risk assessment performed by their doctors. Then, if any coordination of care from multiple sources is detected, the patient is limited to a single pharmacy to dispense all medications. 1 The program's success in limiting opioid prescribing and abuse has led both public and private insurers to adopt similar methodology.

Sam Odishoo
March 27, 2017

References Page

1) "Costs of US Prescription Opioid Epidemic Estimated at $78.5 Billion." Science Daily, 14 September 2016, https://www.sciencedaily.com/releases/2016/09/160914105756.htm Accessed 2 March 2017.

2) Moghe, Sonia. "Health Insurance Companies Step up to Fight the Opioid Epidemic." CNN, http://www.cnn.com/2016/05/19/health/health-insurance-companies-opioid-epidemic/. Accessed 28 February 2017.

3) Mclaughlin, Lori. "Anthem Inc Sets Aggressive Goals to Help Prevent Addiction, Increase Access to Care." Anthem Inc, http://ir.antheminc.com/phoenix.zhtml?c=130104&p=irol-newsArticle&ID=2238162. Accessed 2 March 2017.

4) "How Do We Keep Opioid Pain Relief From Destroying Lives?" Aetna, https://news.aetna.com/2016/06/opioids-destroying-lives/. Accessed 2 March 2017.

5) "United Healthcare Addresses Increased Opioid Use and Dependence." United Healthcare, 3 March 2017, https://broker.uhc.com/articleView-17825. Accessed 5 March 2017.

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