Case Study
Combatting Opioids: Proactive and Retrospective Approaches


Pain has become an epidemic in the United States. One-third of Americans suffer from chronic pain1, and half of those suffering from pain have little or no control over it.2 Deaths from drug overdose have been rising steadily over the past two decades and have become the leading cause of injury and death in the U.S.3

Opioids are a big piece of that puzzle. Opioids are controlled narcotic medications prescribed to relieve pain. Types of medications classified as opioids include Hydrocodone (Vicodin), Oxycodone (Percocet), OxyContin, Methadone and Codeine.

Unfortunately, there is no existing gold standard for identifying those individuals who present a high-risk pattern of opioid abuse.4 However, the U.S. has made it a priority to conquer the epidemic.

As a pharmacy benefit manager committed to improving member health, Navitus understands its responsibility to tackle this nationwide epidemic. Navitus employs a number of strategies and programs to reduce waste and abuse of opioids.


Proactive Approach

As stewards in pharmacy benefit management, Navitus is committed to providing proactive approaches to combat potential cases of opioid abuse. By offering innovative point-of-sale edits, prescriber interventions that facilitate open lines of communication, and high-touch formulary management, we ensure that providers and patients have the tools they need to avoid potential opioid overutilization and abuse.

We created an Opioid Overutilization point-of-sale edit that evaluates each opioid claim as it is processed, based on the member’s medication history. If a member reaches predetermined criteria, (e.g., opioid days’ supply, number of opioid claims, number of opioid prescribers, and number of opioid pharmacies), the claim is denied at the pharmacy level and will not receive reimbursement. For a patient to continue the therapy, he or she must have a prior authorization in place.

In addition, we have implemented a Morphine Equivalent Dose (MED) edit. This edit works proactively by alerting pharmacies and Navitus to abuse issues by detecting members who:

  • have prescriptions for more than 120mg MED,
  • have used multiple pharmacies, and
  • have used multiple prescribers for active opioid claims.

This edit is based on recommendations from the Centers for Medicare and Medicaid Services (CMS) for CMS morphine equivalent dose specifications. The edit identifies and potentially minimizes excessive opioid utilization.

When pharmacies run claims for members with unsafe doses of opioid medications, the claim is denied at the pharmacy and provider involvement is coordinated.

Finally, we utilize a formulary management strategy to ensure there are checks in place before members use opioid prescriptions. Our strategy focuses on mitigating abuse by researching, reviewing and discussing abuse-deterrent products and implementing Step Therapy, Quantity Limit, and Prior Authorization programs. Our Pharmacy and Therapeutics (P&T) Committee also works diligently to ensure our formulary offers quality, evidence-based products.

Retrospective Approach

Using retrospective data is a tried-and-true method used to communicate with prescribers regarding potential member opioid abuse. Below are ways in which we use this reliable approach to combat opioid abuse.

Alerting Providers to Potential Abuse through Retrospective Claims Analysis

Navitus’ Retrospective Drug Utilization Review (RDUR) programs focus on determining the appropriateness, necessity, quality and reasonableness of medication therapies using retrospective claims analysis, based on a predefined period of time, when applicable. These programs curb opioid abuse and deliver interventions, including member profiles, to appropriate prescribers.

  • Controlled Substance Monitoring (CSM): Identifies members with potential overuse of controlled medications (Schedules II through V). The profiles identify high numbers of prescribers, pharmacies and/or prescriptions for controlled medications during the last four months.
  • CMS Repeat Alert: Identifies members who have been included in the CSM program at least four times over a two-year period.
  • Expanded Fraud, Waste & Abuse: Identifies members receiving multiple prescriptions for drugs with high potential for abuse. Drug categories for this program include muscle relaxants, migraine medications, and other medications that are not scheduled (not included in CSM), but have potential for overuse or abuse.

In addition, our Multi-Prescriber, Multi-Prescription and Duplicate Therapy programs work to combat opioid abuse by identifying members visiting multiple providers and using multiple drug regimens, as well as members who use multiple medications with similar therapeutic purposes.

Retrospective Opioid Overutilization Case Management

This program provides regular telephonic and/or fax outreach to prescribers. Members are eligible for this program if their morphine equivalent dose exceeds 120 mg in a specific timeframe determined by a reviewing clinician/clinical pharmacist, and if they have used more than three prescribers and more than three pharmacies during the same timeframe. This methodology identifies those individuals most at risk for safety concerns related to drug overutilization.

The reviewing clinician may also suggest interventions based on a review of members who have nearly met all three conditions outlined above and where the reviewing clinician believes an intervention may be needed.





Double- and Triple-Threat Programs: New Products to Continue Combatting Opioid Abuse

Pharmacy Quality Alliance, Inc. (PQA), a consensus-based, multi-stakeholder member organization committed to improving health quality and patient safety with a focus on the appropriate use of medications, developed a Concurrent Opioids and Benzodiazepines Measure. Navitus is modeling its own RDUR Triple- and Double-Threat programs after PQA’s measures.5

Our Triple-Threat Program identifies members who are taking opioids, benzodiazepines/sedative hypnotics, and muscle relaxants concurrently. This combination puts members at a higher risk for abuse and overdose. To combat this higher risk, Navitus will send prescribers complete patient profiles (noting the patient’s opioid, benzodiazepine/sedative hypnotics, and muscle relaxant medication fills) for review. We also are building a Double-Threat program. This program will work much like Triple-Threat, with the exception that Double-Threat will focus on the concurrent use of opioids and benzodiazepines/sedative hypnotics only.


By putting proactive and retrospective protections in place, we can support improved health and quality of life for members and help fulfill our commitment to battling opioid abuse. The following outcomes highlight the success of these programs.

Opioid Overutilization Edit Outcomes

Navitus staff performed a study, Opioid Over-Utilization Point-of-Sale Edit in a Commercial Population: A PBM Evaluation, which revealed interesting results.6 Significant improvement in the number of opioid prescribers, day supply of opioids, number of opioid claims, and opioid dispensing pharmacies were observed when comparing monthly averages to the last month of the study (p<0.05). There was also a significant decrease in total plan paid (p<0.05).

The study concluded that 1) a point-of-sale edit at the pharmacy level is a reasonable approach to curb opioid overutilization, 2) intervention increases coordination of care between health care providers and insurance, and 3) opioid overutilization can be curbed with the right tools, provider education, and coordination of care.

MED Edit Outcomes

Another Navitus study, Implementation of CMS Recommended MED Point-of-Sale Edit in a Medicare Part D Population, concluded that Medicare Part D patients could potentially benefit from the MED point-of-sale edit.7 Descriptive statistical analysis was performed on all prescriptions that met the MED point-of-sale edit criteria within the first six months of activation of the edit. The study showed that a point-of-sale edit can result in a significant decrease in opioid over-utilization and a reduction of total plan-paid. Additional outcomes included:

  • A total of 75 prescriptions triggered the MED point-of-sales edit in the 6-month study. These 75 prescriptions were associated with 41 unique members. Twenty-six members had one prescription that triggered the edit and the remaining 49 prescriptions were submitted by 15 members. The greatest number of edits per member during the 6-month period was seven.
  • During the 6-month period, 1,622 members within the plan had at least one opioid prescription filled and the MED point-of-sale edit identified 2.53 percent of these members (41/1622).

Retrospective Drug Utilization Review (RDUR) Outcomes

Our RDUR safety programs exhibit 33 to 34 percent behavior improvements. Behavior improvements occur when members are not re-identified four months post-intervention (meaning they no longer meet the thresholds for the particular safety intervention).

Also, the CSM Repeat Alert displays an overall success rate of 52.41 percent. A successful outcome occurs when the member is not re-identified four months post-intervention, meaning the member no longer meet the thresholds for the CSM intervention.

Formulary Management Outcomes

Applying a Quantity Limit of 120 OxyContin CR tablets per 30 days prevented an average of 338 excessive claims per quarter over a 24-month period.



1 AAPM Facts and Figures on Pain page. The American Academy of Pain Medicine website. Accessed November 11, 2013.

2 Pain and Opioid Misuse in America: fact sheet. Care Alliance website. Published 2010. Accessed November 10, 2013.

3 Centers for Disease Control and Prevention. Wide-ranging OnLine Data for Epidemiologic Research (WONDER) [online]. Published July 28, 2014. Available from URL:

4 Daubresse M, Gleason PP, Peng Y, Shah ND, Ritter ST, Alexander GC. Impact of a drug utilization review program on high-risk use of prescription controlled substances. Pharmacoepidemiol Drug Saf. 2014 Apr;23(4):419-27. Doi:10.1002/pds.3487.

5 Wigdal C, Wickizer M, Hurst M, Murphy E, King S, Olson J, Topp R. Triple Threat: Analysis of Opioid, Benzodiazapine, and Muscle Relaxant Discontinuation after Pharmacy Benefit Manager Intervention to Prescribers [273812-Poster Presentation].

6 Hipara S, Wickizer M, Simani J. Opioid Over-Utilization Point of Sale Edit in a Commercial Population: A PBM Evaluation [F-Podium Presentation]. Journal of Managed Care Pharmacy. 2014;20(suppl 10=a):S7.

7 Olson J, Wickizer M, Johnson N, Wigdal C, Topp R. Implementation of CMS-Recommended MED Point of Sale Edit in a Medicare Part D Population [U16-Poster Presentation]. Journal of Managed Care Pharmacy. 2015;21(suppl 10-a):S76.


Show more case studies >