1. Employees Retirement System of Texas (ERS) Changing the Script
November 8, 2018

2. Changing the script
A unique, collaborative health plan approach to the opioid-epidemic from the perspective of one health plan that is working to change the script!
Intended to drive a unified benefit plan solution among independent vendors, administrators and health plan experts.
Demonstrates our support of our participants, their loved ones and our communities
This comprehensive health plan strategy includes pharmacy, medical and behavioral health focus to:
Help prevent dependency before it starts
Stop progression to opioid misuse, abuse and addiction
Treat and support chronic utilizers on the path to recovery
Promote savings and quality of care

3. This is not the anti-opioid project
“While it’s well-documented that these medications remain overprescribed, opioids represent very effective options for managing pain for select chronic medical conditions like cancer and end-of-life care, and in short-term treatment of more severe acute pain where alternative therapy may not be suitable.
Despite the attention drawn to the epidemic and the excess supply of these medications on the market today, we must also remain conscientious of the large numbers of patients with chronic, debilitating pain who rely on opioids to improve their quality of life and overall function, and ensure appropriate access to viable, effective, non-opioid treatment alternatives.”
David Calabrese RPh, MHP, Senior Vice President and Chief Pharmacy Officer, OptumRx

4. ERS took quick action
Project group engages regularly to share ideas, actions, data and solutions, including those from medical, pharmacy, behavioral health and benefit plan (plan sponsor)
Overprescribing remains a concern and the health plan adopted CDC guidelines quickly through the PBM’s opioid risk management program.
The plan design was adjusted to allow open access to all Medication Assisted Therapies (MATs) without prior authorization or other obstacles. The different options may however be covered at different copay tiers.
MAT OPTION
ORX
buprenorphine (generic Subutex)
Tier 1 generic
buprenorphine/naloxone (generic Suboxone tabs)
Suboxone film (brand)
Tier 2 Preferred Brand
Zubsolv (buprenorphine/naloxone) sublingual tab
Vivitrol (naltrexone) long-acting injectable
Bunavail (buprenorphine/naloxone) buccal film
Tier 3 Covered Brand

5. ERS took quick action
Behavioral health access expanded September 1, 2018 for participants with ability to schedule appointments via virtual visits (Doctor on Demand and MD Live)
Member education plays a crucial role in the prevention of opioid misuse, dependency, and diversion before it occurs.  As part of this effort, members are sent letters when filling a short acting or long acting opioid.  These letters highlight the risks of taking opioids, and provide reminders of quantity limits, alternative pain management options, appropriate storage, and safe disposal.
Data is now shared between the health plan’s vendors to coordinate, measure and preserve the highest quality in health outcomes and to reduce Opioid Utilization Disorder (OUD).

6. Preliminary results 2017 – 2018 January through October
Short Acting Opioids (SAO)
Long Acting Opioids (LAO)
Total Utilizers
-28.8%
-59.8%
Treatment Experienced Utilizers (TX EXP)
-42.2%
-56.3%
New to Therapy Utilizers
(NTT)
-36.6%
-92.5%
TX EXP and NTT Utilizers may be counted in more than one category and will not total due
to edits
TX EXP – members with opioid Rxs > 15 days supply within most recent 120 day claim
NTT – members without opioid Rxs > 15 days supply within most recent 120 day claim
history

7. Preliminary results 2017 – 2018 January through October
SAO Claims Compliant with CDC Opioid Prescribing Guidelines
2017
2018
Non-compliant
25.3%
3.5%
Compliant
74.7%
96.5%
Non-compliant – opioid Rxs that exceed CDC prescribing guidelines
Compliant – opioid Rxs that do not exceed CDC prescribing guidelines

8. Opioid Risk Management Program
Current state:
New to treatment members: Maximum of 49 morphine equivalent mgs per day and 7 day supply on all new short acting opioid scripts; limit of two 7 day supply fills within a 60 day timeframe
Treatment experienced members: Drug specific maximum of 90 morphine equivalent mgs per day; limit of two fills within a 60 day time frame
Narrow refill window of 90% at retail and 80% at mail to limit early refills and stockpiling
Prior authorization on all "first fill" for a long acting opioid
Point-of-Sale Safety Edits (soft reject)
Opioid + Benzodiazepine; Opioid + Medication Assisted Therapy; Opioid + Prenatal Vitamin
Cumulative MED dosing edit
DEA controlled Rx prescribing authority hard edit 
Prior authorization on opioid based cough preparation in patients 19 years or younger
Effective 4/1/18, Member Education ORM program launched where members will receive one short acting or long acting opioid trigger letter per year
Effective 7/1/18, members are restricted to filling a 30 day supply of opioids with ORx Home Delivery
Opportunities underway:
Retrospective DUR
Provider outreach regarding patient-specific opioid clinical opportunities
Dosing, dangerous drug combinations, therapeutic duplication, excessive early refills, prescriber/pharmacy shopping
Intensive Case Management - High risk utilizer intervention
Pharmacist opioid case review for high-risk opioid overuse, as well as acetaminophen early refills
Prescriber outreach, consultation, and action planning
Drug-level lock-in