Anthem funnels high-risk patients to single pharmacy site | Behavioral Healthcare Executive Skip to content Skip to navigation

Anthem funnels high-risk patients to single pharmacy site

June 1, 2016
by Tom Valentino, Senior Editor
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Anthem health plans have launched an initiative designed to reduce the risk of addiction to opioids and other prescription medications by limiting pharmacy choices for high-risk plan enrollees. Under the Pharmacy Home Program, which began April 1, plan members who are deemed to be at risk after meeting a series of criteria are restricted to drug coverage from a single pharmacy of their choosing.

The program attempts to identify doctor shopping and frequent refills. Although prescription drug monitoring databases can help prescribers and pharmacies flag high-risk behavior, Anthem aims to addresses gaps in the system.

“While prescription drug monitoring databases recording medication purchases are available in most states, some are more robust than others, and data can lag in real-time use,” Colleen Haines, staff vice president of Anthem pharmacy services, told Behavioral Healthcare in an email statement. “Also, they require prescribers to look in another database to get information on their patients.”

To be placed in the Pharmacy Home Program, plan members must meet the following criteria within a 90-day period:

  • Fill five or more controlled-substance prescriptions, or fill 20 or more total prescriptions;
  • Visit three or more health care providers for controlled substance prescriptions, or 10 or more providers not limited to controlled substances; and
  • Fill controlled substance prescriptions at three or more pharmacies, or fill prescriptions not limited to controlled substances at 10 or more pharmacies.

Members who meet the above criteria are issued a letter of notice and given 60 days to change their behavior. Failing to do so, they are placed into the Pharmacy Home Program and sent a letter requesting the selection of a pharmacy where, with few exceptions, they will be able to fill medications for one year. Those who have a diagnosis or prescription history for HIV, sickle cell anemia, multiple sclerosis, cancer, and hospice and palliative care are exempt from the Pharmacy Home Program.

As drug overdose-related deaths climb, the single-pharmacy program is part of a wide-ranging effort by Anthem to combat opioid and prescription drug addiction. For example, other initiatives include covering peer support services in some Medicaid programs and automatic referrals to a case manager for those with addiction claims.