IMPORTANT: Keep Your Provider Directory Information Current to Protect Your Network Status. Learn more

Highmark Further Addressing Opioid Use 

Coverage Measures, axialHealthcare Program Intended to Address Growing Opioid Crisis

Like you, Highmark sees the safe, effective use of prescription drugs by our members, your patients, as a main priority.

That is why, effective March 8, 2018, Highmark implemented opioid measures designed to assist the clinically appropriate use of these medications while proactively preventing the development of opioid use disorder.

There will be exceptions for members with cancer or other terminal illnesses.

These measures follow CDC and Highmark guidelines:

  • Short-acting opioids: For individuals new to therapy, initial prescriptions will be limited to seven days. Prior authorization applies. These patients will receive a maximum 14-day supply for short-acting opioids within a 30-day period without additional authorization, provided that each prescription does not exceed the seven-day limit.
  • Long-acting opioids: Prior authorization is required, with confirmation of diagnosis, for new users to initiate therapy.

Highmark designed these measures with member safety as the primary goal.

“Even at low doses, taking an opioid for an extended period of time increases the risk of addiction,” said Sarah Marche, PharmD, vice president of Pharmacy Services for Highmark Inc. “The idea of this program is to stop inappropriate, long-term use at the outset. This policy is completely about the safety of our members and the communities that we serve.

“Data from the CDC show that people who use opioids for just one day have a 6 percent chance of becoming addicted,” Marche added. “For those who use opioids for more than a week, the chances increase to more than 13 percent.”

She noted there are some exceptions to the program, including members who have a condition that causes chronic pain that can’t be managed with other treatments or who may need opioids for acute or chronic pain associated with cancer or other malignant conditions.

Valuable resources can be found on the website for Pennsylvania's Prescription Drug Monitoring Program (PA PDMP). These resources can assist you in identifying patients struggling with substance abuse disorder. The site also offers access to other expansive resources, including:

  • Prescriber Q&A
  • PDMP Tutorials & Policies
  • Opioid Prescribing Guidelines
  • Patient Education Materials
  • Provider Resources on:
    • Talking with Patients About Their Drug Use
    • Identifying Red Flags for Addiction and Diversion
    • State Resources Available to You

You also can consult Highmark's Clinical Practice Guideline for opioid use that's available on our online Provider Resource Center.You also can consult Highmark's Clinical Practice Guideline for opioid use that's available on our online Provider Resource Center. On the Resource Center, click on Education/Manuals and then on Clinical Practice and Preventive Health Guidelines. In the 2018 Clinical Practice Guidelines section, click on Prescribing Opioids for Chronic Pain Guideline and Key Points.

Highmark will remain vigilant and continue to support you in addressing the opioid crisis to keep our members — your Highmark patients — safe. Watch Provider News for updates about these ongoing efforts.

axialHealthcare Program Succeeding, Expanding

As reported in recent issues of Provider News, Highmark has joined forces with axialHealthcare, a national leader in safe and effective pain management and opioid therapy.

axialHealthcare’s resources provide a more comprehensive view of patients’ medication use, such as multi-prescriber activity, adverse drug interactions, overdose, and addiction. Highmark’s collaboration with axialHealthcare began in West Virginia and expanded to Pennsylvania in February 2018.

“We are very confident that our work with axialHealthcare and doctors will drive meaningful change throughout our network,” said Charles DeShazer, MD, chief medical officer for Highmark Inc. “We are going to need many tools to combat this terrible problem. That’s why we are expanding the program to Pennsylvania. We expect positive results here, just as we’ve seen in West Virginia.”

To date, the results in West Virginia are impressive:

  • More than 250 providers received extensive, targeted clinical consultation on pain management.
  • Patients receiving opioids from multiple prescribers dropped by more than 28 percent.
  • Patients receiving opioids in addition to certain sedatives — a significant risk factor for opioid overdose — fell by more than 25 percent.

axialHealthcare has resources you can use that can be accessed directly from NaviNet®. Log into NaviNet, navigate to My Health Plans, and choose the appropriate Highmark health plan. Under Workflows for this Plan, select Auth Inquiry and Reports and then Pain Management Program Portal. Select the appropriate billing provider and click Submit.*

*Please note: Access is at the office and user level. It can be disabled for any user by your security officer.

Watch Provider News for updates on the axialHealthcare program and how it is helping Highmark to successfully address the opioid crisis.