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Is Your Insurance Company Monitoring You for Drug Abuse?

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Your insurance company may be looking over your shoulder to see if you’re abusing prescription drugs.

That’s because your insurance company often knows even more than your doctor does when it comes to your prescription drug habits.

While the idea behind prescription drug monitoring programs is to alert your doctor if you have been getting prescriptions filled by other doctors, most doctors admit they do not have time to check the database.

Your insurance company, meanwhile, has real-time data every time you use your insurance to pay for a prescription. They also will know if you end up in an emergency room after overdosing, something that many doctors miss if you don’t tell them. A recent study showed that 91 percent of people who overdose continue to get painkillers refilled by a doctor.1

91 percent of overdosers continue to get prescriptions from doctor

Anthem BlueCross BlueShield and Cigna both announced this spring that they are monitoring painkiller use among their members and taking measures to reduce it. If your insurer decides you are filling too many prescriptions by too many doctors, or if you are visiting the emergency room too often, they will require you to have your scripts filled at just one pharmacy. If they still think you are filling scripts too often, they will refuse to pay for them.

“Clearly, the overuse and abuse of prescription drugs has evolved into a national epidemic and a public health emergency,” said Larry Schreiber, president and CEO of Empire BlueCross BlueShield, in a news release.2 “Health insurers are uniquely positioned to help improve prescription drug safety and healthcare quality as we have real-time access to information on medication use to determine if members are using multiple prescribers or several pharmacies to obtain their medications, which often correlates with addictive behavior.”

Anthem decided to initiate the one pharmacy opioid diversion program after first testing it among users of its Medicaid plans. “We know from Anthem Medicaid plans that efforts like this can result in large drops in opioid prescriptions and lead to more appropriate treatment for substance abuse and pain management,” said Jack Stephenson, president of Empire BlueCross BlueShield Health Plus, in the news release. “This program is just one part of our overall strategy to help prevent addiction, redirect members to appropriate care, and hopefully prevent deaths and major medical problems from overdose and drug interactions.”

How the Program Works

Customer activity at pharmacies during a 90-day window will set off algorithms to alert Anthem that a policyholder may be abusing opioids. Those include:

  • Filling five or more prescriptions for controlled substances or 20 total prescriptions of any kind.
  • Visiting three or more healthcare providers to fill controlled substances or seeing 10 or more providers for prescriptions of any kind.
  • Using three or more pharmacies to fill controlled substances or visiting 10 or more pharmacies for any prescriptions.

Meanwhile, Cigna has launched a similar program. In doing so, they even set a target of reducing opioid use among its members by 25 percent in three years.

“To respond to this crisis, all stakeholders – patients, physicians and other providers, pharmaceutical manufacturers and distributors, payers, pharmacists and governments – must join together to prevent substance abuse disorders, and assure access to all appropriate treatments,” Cigna President and CEO David M. Cordani declared in a news release.3

The Cigna news release went on to say it will be “limiting the quantity of painkillers when appropriate, and exploring additional controls for high-risk customers identified by Cigna’s data on its customers. Cigna continually enhances its tracking programs to flag possible inappropriate use and to inform prescribers when an issue is identified.”

Insurers Could Save Both Money and Lives

It’s no wonder insurers are instituting these types of programs. Not only will they hopefully save lives, but they will also save payers on the costs of opioid prescriptions. And the savings to insurance companies could be far, far greater than that.

For example, Anthem administers Indiana’s Medicaid and Healthy Indiana (Medicaid expansion) programs. In Indiana and around the nation, opioid addiction has led to an HIV/Hepatitis C epidemic among injection drug users.

Last year, a massive outbreak of both diseases in one small Indiana county among injection drug users rattled the entire nation. In the months that followed, the outbreak extended beyond Indiana to the Appalachian states. If you are an injection drug user recently diagnosed with HIV and/or Hepatitis C, here’s a link to find help: Chronic illness such as Hepatitis C and HIV often travel on the same dirty needle.

According to the News and Tribune (of Jeffersonville, Indiana), the cost to the state of Indiana to treat these injection drug users for their newly acquired chronic diseases was expected to surpass $58 million as of December 2015.4 In June, the Wall Street Journal reported that to treat “just a fraction” of people now similarly infected in 220 counties around the nation may surpass $1 billion (yes, billion, with a “b”).5

Dr. Andrew Kolodny of Brandeis University’s Heller School for Social Policy and Management told CNN that the clout the insurance companies carry is not to be underestimated. “They’re paying the bills. They’re paying for the medicines that people are getting addicted to. They’re paying for the doctors’ visits when people are getting medicines prescribed. They’ve got quite a bit of influence in this.”


1. Heitz, D. Astonishing Study: Almost Everyone Who Overdoses on Painkillers Continues to Get Refills from a Doctor. Retrieved Aug. 10, 2016, from
2. Empire BlueCross BlueShield launches Empire Pharmacy Home Program. (2016, May 27). News release. Retrieved Aug. 10, 2016, from
3. Cigna outlines steps to help curb national drug epidemic. (2016, May 19). News release. Retrieved Aug. 10, 2016, from
4. Hayden, M. HIV outbreak costs state $58 million. (2015, Dec. 17). News and Tribune. Retrieved Aug. 10, 2016, from
5. Campos-Flores, A. et al. (2016, June 3) CDC Identifies Counties at Risk of HIV Outbreaks. Washington Post. Retrieved Aug. 10, 2016, from

Written by David Heitz


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