The chief health officer in 2014 recognized the impact of the opioid crisis on Blue Shield of California’s members. Narcotic analgesics were among the most frequently prescribed drugs. Hydrocodone and its variants topped the list, with three to four times more prescriptions than OxyContin, the second most commonly prescribed opioid. The chief health officer received endorsement for the Narcotic Safety Initiative from Blue Shield of California’s board of directors and asked the director of clinical pharmacy programs to lead the effort, saying, “If we do not act now, it is only going to get worse.” Both Blue Shield of California leaders recognized that health plans have a role in helping to reduce overprescribing and overuse of prescription opioids. As the executive sponsor, the chief health officer drove participation across the organization, while the director developed the program strategies and led their implementation.

In 2015 Inland Empire Health Plan (IEHP) joined a coalition of community and health care stakeholders concerned with the opioid crisis. The coalition is a place for organizations to take ownership of their roles in addressing the opioid crisis, and to act collaboratively with otherwise unlikely partners beyond their individual goals and needs. The coalition developed a toolkit for hospital emergency departments (EDs), which it implemented in 2016 and 2017. In 2017, the coalition came back together to assess its progress and discuss next steps. IEHP and other stakeholders agreed that the coalition could have the greatest impact by expanding its efforts to develop community- and provider-facing strategies. The coalition is still in operation today.

Kaiser Permanente Southern California (KPSC) saw the opioid crisis emerge through its data. What the organization first thought was an issue with increased pharmacy volume due to its electronic health record turned out to be increased prescribing of opioids. The combination of internal pharmacy and medical record data uncovered the issue by showing a substantial trend in increased opioid prescribing.

Partnership HealthPlan of California (PHC) discovered that Vicodin (hydrocodone) was its most frequently prescribed medication. Opioid use and overdose rates were high throughout the counties in its network. Primary care providers were vocal; they found pain management work to be dissatisfying compared to the rest of primary care. Patients were also frustrated: They remained in pain despite being on high doses of opioids. A triple threat — the high cost of opioids combined with provider and patient dissatisfaction — drove PHC to take action.

Blue Shield of California recognized that addressing the opioid crisis would not be just a pharmacy initiative. It engaged key players across the organization who understood the key levers that needed to be used to drive change — medical policy, formulary management, benefits, programs supporting members and providers, provider credentialing, analytics, etc. Together, this cross-functional leadership team leveraged existing approaches and launched new ones to reduce the number of members on chronic opioids for chronic noncancer pain, prevent the progression from acute to chronic use, and provide appropriate treatment for chronic pain and addiction.

The team developed pharmacomedical analytics with a data-driven dashboard to look at the key medical and pharmacy metrics, assess the impact of interventions, and evaluate progress over time. Analytic support and expertise were key elements of the initiative; data-driven insights helped guide and inform the leadership team. For example, the analytic model to identify and exclude members from interventions and reporting (e.g., those with cancer, in hospice or palliative care, etc.) based on information available to the health plan required refinement over time because it was not as straightforward as originally thought.

An internal governance structure provides accountability for the initiative. A steering committee and workgroups meet routinely to develop and monitor activities, and results of the initiative are reported through Blue Shield of California’s quality committee structure. An unplanned result of this enterprise approach is the ability for the group to address new national quality measures on opioid use (see more at www.ncqa.org).

IEHP assumed organizational and administrative responsibility for the coalition in mid-2017. It formed six workgroups: (1) access to treatment, (2) overdose/access to naloxone, (3) education and engagement, (4) ED toolkit, (5) reporting/outcomes, and (6) reducing prescriptions. Data from the California Department of Public Health (CDPH), which were disseminated by the California Health Care Foundation, helped define the issues each workgroup would tackle, along with baseline metrics against which the workgroups would measure their progress. These workgroups are still in operation today. A steering committee composed of coalition leadership oversees the workgroups, while all participants on the coalition are expected to take part in at least one workgroup.

Using a quality-improvement methodology, PHC developed a driver diagram, identifying the levers it could use to drive change internally. The driver diagram helped identify who needed to be involved and their respective roles. A steering committee was created with leadership from every department. Workgroups were formed on pharmacy, member services, provider relations, and other key topics, and engaged network providers in planning efforts to ensure that new policies were helpful and not harmful to providers and patients.

Part of Blue Shield of California’s strategy is to work with the broader health plan community in local and state coalitions under the belief that opioid safety should be a plan-agnostic endeavor — all stakeholders must work together to drive significant change. For example, it participates in Safe Med LA, a broad, cross-sector coalition of stakeholders addressing the opioid epidemic in Los Angeles County. Safe Med LA has helped reduce prescription opioids in county emergency departments through targeted communications and education. Blue Shield of California is also active in state and federal legislative efforts to fight the opioid epidemic.

The coalition publishes a monthly newsletter communicating strategies and progress. It also regularly looks to CDPH data to back up its strategies and uses these data in its communications with stakeholders. Communicating a compelling case has not been difficult in the Inland Empire. Clinicians know people affected by the epidemic and many feel personally responsible because of their field’s actions.

As a first step, the steering committee quickly developed a plan to target medications at risk for misuse by teenagers, such as OxyContin, Opana, and Soma. KPSC focused its efforts on reducing prescribing of these medications and saw an almost immediate 98% reduction in prescribing of brand-name opioids. It simultaneously undertook an education campaign to communicate and spread its goals of reducing the prescribing of medications at risk for misuse among teenagers and of curbing the leakage of opioids into schools.

PHC created a call to action around the high death rates in its counties, enlisting local opioid safety coalitions and clinic leaders in the need for change. Any major policy rollout allowed time for ample provider feedback, and the pace was adjusted to balance patient safety (e.g., the risk of overdose death with high opioid doses) with the need to avoid harm. For example, PHC began requiring prior authorizations for high-dose opioids, but exempted patients from tapering if they had medical or psychiatric instability, or if the regimen was deemed appropriate by a local peer review committee.

At the start of the initiative, Blue Shield of California stakeholders were skeptical that anything could be done to address the opioid crisis. Medical standards of practice and physician training led to the aggressive treatment of pain, and opioid medications were commonly prescribed as a first choice. Blue Shield of California leadership met frequently with provider organizations and individual prescribers, sharing data and convincing stakeholders of both the problem and the strategy that would steer prescribing and opioid use to lower levels. Leadership asked providers to guide policy changes and adapted interventions based on feedback. The increasing public awareness of the opioid epidemic and the publication of new national prescribing guidelines from the Centers for Disease Control and Prevention also helped to improve acceptance of Blue Shield of California’s Narcotic Safety Initiative.

The coalition hosts quarterly meetings to provide an opportunity for all workgroups to meet, celebrate successes, share information, and remove obstacles to goal achievement. The “access to treatment” workgroup partners with 8–10 primary care providers and Federally Qualified Health Centers (FQHCs) to integrate behavioral health and medication-assisted treatment (MAT). The workgroup learned that Arrowhead Regional Medical Center, a county hospital system, had been awarded a grant to improve transitions of care. As a result, the workgroup expanded its scope to include bridging between county EDs and primary care offices.

Maintaining a successful and meaningful coalition requires resources and leadership, which are both difficult to maintain. The coalition is constantly looking for new funding sources to support its work. The workgroups that have made the most progress have committed industry and community leaders who, in addition to their day jobs, invest their time and energy into the coalition and its efforts.

Some physicians were resistant to change. KPSC made a concerted effort to reeducate physicians on the impact of opioids and on appropriate prescribing practices. Today, all physicians are expected to prescribe appropriately; if outlier prescribers are identified, KPSC intervenes and provides individualized education and monitoring.

Physicians were worried that their patient satisfaction scores would drop if they refused to prescribe opioids. In response, KPSC adjusted its survey practices so physicians no longer had to worry that safer prescribing practices would impact patient satisfaction scores.

PHC recognized that its physician network could not change its prescribing habits overnight. PHC spent hundreds of hours in meetings with physicians, communicating why PHC was making changes in prescribing practices, what those changes were, and the impact they expected to achieve. PHC also heavily invested in provider training and in offering consultation support to providers for complex pain management patients. Finally, PHC rolled out changes slowly and incrementally, with substantial advance communication.

The development of a meaningful dashboard to report and monitor prescribing practices among Blue Shield of California’s network of providers was a critical first step. Pharmacomedical analytics remain central to its efforts today and have helped the organization identify its wins. Blue Shield of California’s partnership with CHCF enabled Blue Shield to build momentum in its efforts. CHCF recognized health plans’ roles in combating the opioid epidemic and endorsed Blue Shield of California’s internal efforts through publication of a white paper and case studies (PDF) in 2016.

When Central California Alliance for Health (CCAH) was trying to understand the extent of the opioid crisis among its members, it built a registry to identify and track patients with or at risk for opioid use disorder (OUD). The registry served an important role in both helping CCAH track and manage the health of its population as well as understand whether it had the workforce with the skills and training necessary to address its members’ needs. The registry enabled them to see how many members might require MAT; therefore, CCAH could identify whether it had enough waiver-trained providers actively accepting and treating OUD and chronic pain patients. Developing a strong foundational understanding of its population and network of providers led CCAH to undertake subsequent initiatives focused on building its network’s capacity to meet member needs.

The Alameda County Health Care Services Agency (HCSA) contracts with the Alameda Health System and eight FQHCs to provide care for approximately 220,000 un- and underinsured people living in Alameda County. In 2014, HCSA recognized that its contracts with providers could be an important lever to progressively increase the number of prescribers with buprenorphine waivers. HCSA started by tying funding to the requirement that every site have at least two waivered prescribers. By the end of 2015, approximately 60 physicians were waivered across the contracted provider sites.

After meeting this goal, HCSA required that providers maintain their numbers of waivered prescribers and demonstrate that each was prescribing buprenorphine to at least 5 patients. In 2017, the requirement grew to 10 patients receiving buprenorphine, and the sites had to accept referrals from the ED-Bridge program. Building on its success to date, the current contract requires providers to show they have a plan for safe harbor for anyone on chronic or high-dose opioids.

CCAH offers financial incentives for providers to complete buprenorphine waiver trainings. Newly trained providers are encouraged to participate in mentor meetings with experienced prescribers to get help with common questions as they begin treating patients with chronic pain and opioid use disorder.

CCAH also supports and participates in the SafeRx Santa Cruz and Prescribe Safe Monterey MAT Advisory Group. The advisory group is a peer support and resource group of physicians, advanced practice clinicians, and behavioral health providers focused on improving opioid use disorder recovery capacity and quality. It meets periodically in person and also pairs local mentors with providers who have, or are interested in obtaining, a buprenorphine waiver. It also offers a Google Group for case discussions and Q&As, and a Google Drive folder with training and prescribing resources.

IEHP is developing a combination of behavioral health integration (BHI) and MAT pilots. IEHP will assist selected network primary care provider organizations in the development, implementation, and integration of MAT and behavioral health services into their practices.

Both BHI and MAT are evidence-based practices. During this pilot, there will be nine physicians newly providing MAT to approximately 500 IEHP members with OUD. There will be eight new behavioral health clinicians providing treatment to approximately 1,500 IEHP members with behavioral health conditions. A year after the grant ends, the number of IEHP members receiving MAT is expected to double to 1,000. The number receiving behavioral health services is expected to increase by 70% to more than 2,500. Both the MAT and BHI pilots will improve health equity by providing care to populations that have been historically stigmatized and have suffered worse health outcomes. In addition to access to treatment, one of the pilot’s primary goals is to decrease bias and stigma held by health care team staff.

Workit Health is one of many new MAT telehealth providers active in California. It was created by Robin McIntosh and Lisa McLaughlin, two women in long-term addiction recovery, to break down barriers to effective, evidence-based care. Patients start buprenorphine treatment at a onetime in-person meeting at a centralized office location (currently, in Michigan and California). Patients then continue care through Workit Health’s online dashboard, where they attend video clinician visits, video drug tests, online recovery meetings, and a personalized curriculum of addiction courses. A recovery coach is available for 24/7 messaging, sending motivational messages as well as appointment reminders.

Commercial and state-funded health plans contract with Workit Health to expand MAT access for their members. In California, Workit Health offers free care to uninsured and underinsured patients, supported by California’s hub-and-spoke program. The flexibility of telehealth allows Workit to take care of patients from distant or rural areas without the demands of continual in-person follow-up visits.

In Michigan, Workit Health contracts with Priority Health, a commercial insurance plan, through a hybrid claims-based and bundled billing model, demonstrating savings on inpatient treatment costs, emergency room visits, and high opioid use. Retention rates for those in the program average around 90%, which is unheard-of for many other types of addiction treatment.

Other telehealth providers active in California and contracting with health plans include Aegis, Bicycle Health, Bright Heart Health, and Groups.

Blue Shield of California provides quarterly reports based on pharmacy claims data to individual opioid prescribers with patients that meet criteria for high-risk use, including total opioid dose of more than 100 morphine milligram equivalents (MME) per day, opioid prescriptions by four or more prescribers or filled at four or more pharmacies within four months, or a prescription profile indicative of a “holy trinity” regimen (those that contain an opioid plus a benzodiazepine plus a sedative hypnotic, muscle relaxant, or stimulant). The patient-specific data are intended to alert providers to patients who are at risk for accidental overdose and to motivate providers to make changes in their patients’ care plans. Since launching these reports, prescribers have also requested that Blue Shield share data on patients at lower doses of opioids. Reporting on both ends of the dosing spectrum has been helpful to stratify patients to the right care plan.

HealthNet, like several other health plans, supports the cost of clinic participation in the UC Davis Project ECHO TeleMonitoring Program. Participants in the program have access to weekly live video sessions with a pain specialist team and evidence-based training from a multidisciplinary team on all aspects of pain management. HealthNet has a second ECHO program that targets pain management and MAT through the Weitzman Institute.

KPSC raised awareness among providers about the risks to patients when converting from short-term to long-term opioid use. KPSC changed the default setting in its electronic health record (EHR) to support lower doses of prescriptions for acute pain. It developed EHR decision support that asked prescribers to reconsider their prescriptions; the alerts were extremely effective and led to immediate drops in specific opioid prescribing.

KPSC also invested heavily in reeducation efforts to counter decades-old beliefs that led to liberal prescribing habits. Clinical pharmacists and physicians provided high-volume prescribers with academic detailing — brief in-person educational sessions focused on evidence and the need for changing practice. Get more information about academic detailing.

Clinical champions held educational sessions at medical centers and department meetings, and KPSC required all clinicians at the time to attend an educational program developed by the University of California, San Diego. All new physicians and residents were required to complete a three-hour online continuing medical education session within their first year. KPSC has also continued frequent communications to clinicians to reinforce messages about appropriate opioid use.

PHC recognized that there was a large problem that the organization needed to address: Its network included the counties with the highest high-dose prescribing rates in California. In 2014, at the launch of its Managing Pain Safely program, small studies showed that, with enough support, patients on high-dose opioids could safely taper to lower doses and find improved pain management and improved function. These studies were all in controlled settings, where the patients received substantial wraparound behavioral health support services.

PHC leaders wanted to respond to the public health emergency — as opioid overdose deaths were also highest in their counties — while avoiding unintended consequences of tapering patients too quickly or too aggressively (such as the risk of pushing patients to illicit drug use and potentially even increasing overdose deaths). A 2017 Department of Veterans Affairs study showed rapid tapers led to increased suicidal ideation and increased use of mental health crisis services.

PHC invited Andrea Rubinstein, MD, a local pain medicine expert from Kaiser Permanente, to give presentations at several provider convenings, and heavily promoted her educational lectures — “The Art and (very little) Science of Tapering Opioid Medications” and “Rational and Irrational Use of Opioids” — to its entire provider network.

PHC attributes its success — an 87% drop in members on high-dose opioids — partly to the organization’s efforts to educate its provider network on the value of patient-centered tapers, with careful assessment for each patient to ensure the benefits of tapering exceeded the risks (17% of patients were too medically or psychiatrically unstable to taper). PHC created a Tapering Toolkit (PDF), which covered some of the key lessons in Rubinstein’s approach:

Don’t aim to taper to zero. Most patients on high-dose opioids, when on them long enough, can never tolerate total opioid cessation — for the same reason that overdose risk is high for patients with opioid use disorder who are made to be abstinent. Tapering to a lower, safer dose, or tapering to buprenorphine (which has a much safer profile), should be considered a success.

The goal of tapering is to make life better — for the patient. Not for the doctor, not for the health system, and not with an arbitrary goal. Many patients are on unnecessarily high doses. Dose reduction reduces risk and improves the quality of life while commonly having little effect on their levels of pain, or at times reducing hyperalgesia.

Look at the whole picture — not just dose level. Understand the impact of the opioid regimen on mental health, medical conditions (such as sleep apnea, bone density), pain, and function. Looking at the real risks and harms of opioids helps win patients over to the benefit of tapering — for them.

Tapering must be customized to succeed. Tapering plans never go as expected. Adapt as you go.

A few patients are too unstable to be tapered. Don’t taper if the patient will get worse. Stop the taper and stabilize if the patient’s function is worsening instead of improving. But most of those at very high doses can tolerate a degree of tapering to safer levels.

CCAH expanded its complementary and alternative medicine benefit for acupuncture and chiropractic care to offer providers and members additional nonpharmacologic resources to treat pain, prior to these services becoming Medi-Cal program benefits. Providers can request up to 20 visits per authorization, and no limit is placed on the total number of authorizations. Evaluation of the pilot program showed that members receiving acupuncture reduced their morphine milligram equivalents dose by an average of 30 mg/day (24%), subjective pain scores decreased from 8.5 out of 10 prior to the program to 5 after the program, and overall, the cost of visits was offset by pharmacy savings. CCAH also expanded its chiropractic benefit to include all covered adults.

IEHP supported the development of a unique “pain center of excellence,” the Desert Pain Clinic. The center of excellence treats very high-risk Medi-Cal patients with behavioral health and chronic pain diagnoses through a holistic approach, using yoga, exercise classes, counseling, and other alternative treatments. IEHP covered the cost of these services through a case rate, as many complementary services are not Medi-Cal benefits. Early data showed extremely high patient engagement rates, with significant improvements in patient functioning, lower pain scores, and lower hospital utilization. IEHP is interested in supporting additional pain centers of excellence, assuming the first one continues to show good results.

Oregon-based Samaritan Health announced in 2016 it would remove prior authorization requirements and session limits for patients seeking physical therapy to treat pain. The change was in response to emerging evidence showing movement therapy and exercise could improve back pain. Prior to this, Oregon Medicaid altered its Medicaid plan to allow beneficiaries to access physical therapy and other nonsurgical and nonpharmacologic approaches to back pain as the priority treatment.

PHC expanded its medical benefit to cover acupuncture and chiropractic care when these services were not mandatory Medi-Cal benefits; it also covers osteopathic manipulative treatment in the primary care setting. While PHC did not see a corresponding drop in opioid prescribing, the additional benefits offered an alternative for patients and a “pressure release valve” for doctors who otherwise felt cornered. The availability of alternative benefits helped prescribers start conversations with patients about their options outside of opioids.

PHC developed an Outreach and Understanding Can Help (OUCH) team of case managers trained to work with members with OUD. The case managers supported members as they tapered and/or transitioned to medication-assisted treatment. Although these specially trained case managers were initially dispersed throughout the care coordination department, today all PHC case managers are trained to work with members who have OUD.

Washington State implemented a system of real-time alerts using Collective Medical Technologies’ Emergency Department Information Exchange (EDie). EDie allows ED physicians to quickly access information about previous ED visits, studies, diagnoses, and medications. This resulted in a 24% drop in visits resulting in a prescription for a scheduled drug, while total Medicaid ED visits dropped by nearly 10% in the first year. EDie is increasingly being used by hospitals across California, and is contracting with health plans for real-time notification of designated high-risk populations.

San Francisco Health Plan (SFHP) is using the PreManage ED communication tool to link to most San Francisco hospitals. Through this tool, SFHP case managers receive near real-time notifications of admissions and insights into shared care planning.

KPSC adopted the American Academy of Emergency Medicine’s Emergency Department Opioid Prescribing Guidelines for the Treatment of Non-Cancer Related Pain (PDF). KPSC stopped offering injectable opioids for the exacerbation of chronic noncancer pain in the ED and would offer only short-course prescriptions (i.e., up to 12 pills) for patients presenting with acute pain. ED physicians and staff assessed whether patients were candidates for MAT and referred candidates to KPSC’s addiction medicine team for follow-up. KPSC coupled this effort with an educational campaign in the ED and achieved very high compliance across its Southern California EDs.

L.A. Care works with its pharmacy benefit manager (PBM) to do retrospective drug utilization review. RDUR identifies prescribers whose patients are at risk of opioid overdose or death due to a combination of prescribed opioids with benzodiazepines and skeletal muscle relaxants. It also identifies patients using nine or more Schedule II–V drugs and/or who have obtained opioid prescriptions from multiple prescribers and pharmacies over a four-month period. The PBM sends letters to prescribers that relates the risk of overdose and death for their patients. The letters have resulted in a steady reduction in opioid prescribing across L.A. Care’s lines of business, including Medi-Cal. Members who obtain prescriptions at three or more pharmacies and from three or more prescribers in a 90-day period may also be locked in to a single pharmacy.

PHC analyzed prescription claims data to identify members on high doses of opioids as well as prescribers with patterns suggesting risk for adverse patient outcomes. PHC slowly advanced policies to support safe tapers to lower doses: first, requiring authorization for dose augmentation above a high-dose threshold, and then over time, requiring providers to submit justification for ongoing treatment with high doses, either attesting that the patient has had the high dose approved by a peer-review committee, or submitting a tapering plan to a lower dose. Exceptions to tapering were granted for medical or psychiatric instability; tapering was judged to be unsafe in about 17% of patients. The medical director and his team investigated prior authorization requests individually and promptly, and worked with prescribers to help them create individualized plans to lower doses where safe and appropriate.

Beginning in January 2018, Aetna waived copayments for Narcan for fully insured commercial members in an effort to increase access and remove financial barriers to the lifesaving drug. Narcan is a brand-name version of naloxone. Prior to being waived, the copayment for Narcan ranged from $0 to $150. When Aetna waived the copayment, it also took steps to limit the quantity of opioids that could be prescribed for acute pain and post-surgery, limiting prescribers to a seven-day supply for commercial pharmacy members.

Aetna, Anthem, and Cigna removed the prior-authorization requirements for Suboxone in late 2016 (Cigna) and early 2017 (Aetna and Anthem). Anthem and Cigna implemented the change after facing an investigation by New York’s attorney general into whether the insurers’ coverage practices impeded patient access to necessary treatment. California’s Medi-Cal program removed the prior authorization requirement for Suboxone in 2015, and quickly saw a significant increase in use.

CCAH is working with pharmacies in Merced to stock and furnish naloxone. This has required one-on-one meetings between the health plan’s leadership (medical director and pharmacy director) and local pharmacies. The efforts to stock naloxone initially faced resistance from pharmacists due to concerns that making naloxone available would increase risky behavior and the likelihood of overdoses. Through ongoing dialogue, CCAH and the pharmacies have been able to work through this issue and bring naloxone into the Merced community.

Health Plan of San Joaquin (HPSJ) collaborates with local organizations in the San Joaquin County Opioid Safety Coalition (SJCOSC) run by San Joaquin Public Health Services. HPSJ is one of the partner agencies selected to serve on the accelerator team (a program of the California Opioid Safety Network) that helps guide the coalition. Other organizations represented include health care providers, community organizations, law enforcement, first responders, and educators.

The SJCOSC was initiated in March 2018. Its aim is to reduce deaths attributed to opioids. With partner enthusiasm and expertise, the coalition has been able to conduct training, community assessments, strategic planning, educational outreach, and group-based academic detailing. An early coalition effort focused on working to prevent overdose deaths by launching a naloxone distribution program. The goal was to distribute naloxone to the friends and family members of people at risk of overdose. To date, the coalition has given away over 900 naloxone kits received through a grant from the California Department of Public Health.

As each of the SJCOSC partners works with urgency and care to test and implement effective solutions, each also is committed to the guiding principle that any measurable, lasting solutions must be woven into an integrated menu of approaches.

In 2015, Santa Clara Family Health Plan (SCFHP) implemented a policy requiring authorization review for doses above 120 MME. Requests were automatically approved with a letter stating:

“This quantity of narcotics exceeds safe prescribing guidelines. Please co-prescribe naloxone injection, one vial, for overdose rescue.”

In 2016, recognizing that prescribers rarely read approval letters (and members never receive them), Santa Clara created a new protocol. All requests for >90 MME (excluding hospice and palliative care) were automatically denied unless a claim for naloxone was on file for that member. Denials triggered a letter to the prescriber and member stating:

“This quantity of narcotics greatly exceeds safe prescribing guidelines. Per Centers for Disease Control guidelines, opioid dosages greater than 90 MME per day are associated with increased risks. [For members receiving high-risk combinations of medications, the letter also read ‘The prescribed dosage and combination with morphine sulfate, oxycodone/APAP, and clonazepam are in the lethal range.’] Please resubmit with a prescription for naloxone injection, one vial, for overdose rescue.”

Once the naloxone prescription is documented, the authorization request is approved. With this approach, the health plan gives a clear message to the member and prescriber about safety without the labor-intensive practice of reviewing each case.