Jan. 8, 2015

In the July 2014 issue of the Blue Review newsletter, we announced enhancements to the Blue Cross and Blue Shield of Oklahoma (BCBSOK) Controlled Substance Program to help identify members with controlled substance utilization patterns that may indicate potential abuse, misuse and/or opportunities for coordination of care.

In addition to the enhanced program criteria, an integrated team was established to review and track identified cases. This review team includes BCBSOK care management and clinical staff, as well as our Special Investigations Department. The team investigates the member’s circumstances and works with the member’s prescribing physician(s) to help coordinate care, determine interventions as appropriate and assist with the development of action plans.

Since the launch of our enhanced Controlled Substance Program, our review team has reported some positive outcomes. Below is an example of how the program worked for one of our members.

Identifying the Case
A routine review of medical and pharmacy claims revealed a pattern of frequent visits to urgent care with prescriptions for controlled substance medications for a particular member.

Initial Evaluation
The claims history for the member was forwarded to the Controlled Substance Program review team for further investigation. The review team learned that the member did not have a primary care physician .The team also learned that the member was struggling with the challenges of a domestic violence situation and caring for children with special needs.

Action Plan and Follow-up
The review team recommended that BCBSOK Behavioral Health Case Management contact the member to conduct an assessment and discuss possible options for care and outreach services.

• First, our Behavioral Health team helped the member establish a relationship with a primary physician.
• Next, the team collaborated with the physician to develop an overall treatment plan that included monitoring the use of prescribed controlled substance medications and educating the member about the importance of taking these medications only as prescribed to help reduce future urgent care visits.
• Finally, our Behavioral Health team connected the member with community resources to help with finding safe housing, filing a domestic complaint with the proper authorities and locating information about programs for special needs children.

Our Controlled Substance Program offers a multi-faceted approach to identifying cases and researching potential underlying causes of potential abuse, misuse or improper utilization of controlled substances. We look forward to sharing more stories of members who have achieved successful outcomes.

Sometimes members may not know where to turn when faced with complex life situations. They may seek your guidance as their trusted health care provider. BCBSOK offers a variety of pharmacy-related and other resources on Blue Access for Members^SM. Additionally, we encourage you to direct your patients to our public Be Smart. Be Well.^® website, at besmartbewell.com, where they can obtain information on topics such as addiction, domestic violence/dating abuse, mental health and more.

Providers are to exercise their own independent medical judgment based upon the patient’s documented medical history and prescription drug use. The programs referenced above do not represent a substitute for the independent medical judgment of health care providers.