June 27, 2014

Supporting Appropriate Use of Prescribed Controlled Substance Medications

Controlled substance prescription abuse is a major public health issue in the United States, contributing to steady increases in emergency room visits and drug overdose deaths.* Blue Cross and Blue Shield of Illinois (BCBSIL) is enhancing its controlled substance clinical review program to better identify members with suspected cases of abuse, misuse or improper utilization and collaborate with the member’s prescriber(s) on care coordination opportunities. Mitigating potential abuse can reduce the risk of adverse outcomes for these members.**

Beginning June 30, 2014, members whose controlled substance utilization patterns are flagged as potential atypical use will be identified using enhanced criteria, such as review of all pharmacy and medical claims data, the number of ER visits, substance abuse indicators and others.

As members are identified, the member’s case is reviewed by an integrated care management committee that collectively determines the appropriate intervention based on the member’s history/profile and submitted additional clinical information from the member’s prescriber(s). BCBSIL will collaborate with the member’s prescriber(s) on care coordination opportunities, as well as conduct member outreach.

If you have any questions, please contact your BCBSIL representative.

*The American Journal of Managed Care (AJMC), August 2013.

**The enhanced controlled substance program is currently only available for fully insured groups and metallic health plans offered for small group/individual retail consumers. Expansion of the program to ASO groups is currently under review.