The goal of the Pharmacy Pain Management (PPM) program is to proactively manage members on multiple opioid therapies to prevent overutilization, identify unsafe and inappropriate opioid use, and address potential fraud, waste, and abuse.
Identified members at risk of opioid overutilization will be evaluation through our Pharmacy Pain Management Program (PPM). IEHP Pharmacy Clinical team will be reviewing member therapy and reaching out to the primary provider to discuss the existence of multiple prescribing providers, member's total opioid utilization, appropriate level of opioid use for the member, and considerations for implementation of a member-level claim edit.
After review and consultation with the prescribing provider, if the member's therapy is determined to be appropriate and medically necessary, no further action will be taken. Results of consultation with provider and findings will be documented.
After review and consultation with the prescribing provider, if the member's therapy is determined to be inappropriate, and the provider recommends member-level point of sale claim edit, the member will be mailed a notification letter that entrails the provider's recommendation. Medicare members will receive the notice 30 days in advance of the point of sale claim edit implementation.
Member may also be referred for evaluation and monitoring by a pain management specialist.