Published on January 10, 2014 at 1:06 AM
Aetna's Pharmacy Misuse, Waste and Abuse program monitors access to opioids through precertification and reviews pharmacy and medical claims and quantity limits to find patterns of above-normal use. Further, members who have had frequent emergency room visits are identified. Other signs and suspicion of developing substance abuse problems or a history of controlled substance abuse also are noted. The program reduced opioid prescriptions among 4.3 million members by 14 percent between January 2010 and January 2012.
Aetna nurses and psychologists in Behavioral Health's Medication Assistance Program work with physicians to evaluate members who could be at risk for addiction. Additionally, members with a history of opioid abuse or who are in treatment are identified and receive behavioral health support services through the Aetna Pharmacy Suboxone Case Review program. The Aetna team helps develop and track treatment plans for opioid dependence. Among participants, the program has shown a 30 percent improvement in opioid abstinence rates; a 35 percent reduction of in-patient hospital admissions and a 40 percent decrease in total paid medical costs. The program recently earned recognition by URAC as a 2013 best practice in consumer engagement and protection.
Members are eligible for the programs based on their enrollment in self-insured or fully-insured Aetna medical, pharmacy and/or behavioral health benefits.