Pharmacy Quality Program

Customers with potential overutilization or inappropriate utilization of narcotics are identified based on approved criteria and reports are produced monthly. Customers with at least three (3) controlled opioid pharmacy claims, four (4) different prescribers, four (4) different pharmacies and 120mg MED (morphine-equivalent dose) for 90 consecutive days within the reporting period of 180 days are included for case management. Any individual with cancer or on hospice care is excluded from the program. The Cigna-HealthSpring Clinical staff review claims data and determine whether further investigation with prescribers is warranted. If intervention is deemed appropriate, the case manager will send written notification to all prescribers by fax requesting information pertaining to the medical necessity of the current narcotic regimen. Cigna-HealthSpring will reach out to discuss the case and consensus must be reached by the prescribers if action is required. In the most severe cases, to assist with control of overutilization, point-of-sale edits may be implemented if the prescriber desires.

Medication Therapy Management (MTM)-eligible customers are offered a comprehensive medication review (CMR) annually. In the welcome letters sent to the eligible customers, Cigna-HealthSpring encourages each customer to call to complete their CMR before their annual comprehensive visit with their primary care provider so the customer can take their medication list to the appointment. After the completion of the CMR, any potential drug therapy problems (DTPs) that are identified are sent to the prescribing provider and/or primary care provider by mail or fax. Along with DTPs, the provider also receives a list of the customer’s prescription history through the previous 4 months. After the CMR, the patient is mailed an individualized letter, which includes a personal medication record of all medications discussed and a medication action plan.

If the customer has any questions or comments about the DTP recommendations a fax and phone number is provided for follow up. In addition to the CMR, providers may also receive targeted medication reviews (TMRs) quarterly. The TMRs are completed electronically to look for specific DTPs. If any DTPs are identified, a letter may be mailed or faxed to the provider.

Cigna-HealthSpring completes a monthly review of drug utilization data of in order to determine the effectiveness, potential dangers and/or interactions of the medication(s). Retrospective Drug Utilization Review (rDUR) evaluates past prescription claim data and Concurrent Drug Utilization Review (cDUR) ensures that a review of the prescribed drug therapy is performed before each prescription is dispensed, typically at the point-of-sale or point of distribution. Cigna-HealthSpring tracks and trends all drug utilization data on a regular basis to enable clinical staff to determine when some type of intervention may be warranted. Targeted providers and/or customers will receive information regarding quality initiatives by mail. Current Retrospective Drug Utilization Review (rDUR) studies that may be communicated to customers or providers include:

  • Overutilization of medications (≥10 drug prescriptions per month)
  • Failure to refill prescribed medications
  • Drug to drug interactions
  • Therapeutic duplication of certain drug classes
  • Narcotic safety including potential abuse or misuse
  • Use of medications classified as High Risk for use in the older population
  • Use of multiple antidepressants, antipsychotics, or insomnia agents concurrently
  • Multiple prescribers of the same class of psychotropic drug

Letters to customers will focus on the rationale for medication adherence and/ or the safety issues involved. Letters to providers will include the rationale of the particular concern being addressed and will include all claims data for the selected calendar period applicable to that initiative. From any initiative, if a provider indicates that they did not write a prescription that has been associated with them or that they were not providing care for the customer at the time the prescription under investigation was written please notify Cigna-HealthSpring using the contact information on the letter.

A multidisciplinary team develops and determines the direction of pharmacy quality initiatives and the initiatives come from a variety of sources, including but not limited to, claims data analysis, Centers for Medicare and Medicaid Services (CMS) guidance, Pharmacy Quality Alliance (PQA), Food and Drug Administration (FDA) notifications, drug studies, and publications.