Opioid Strategy Overview
Drawing on a public health framework, TennCare’s opioid strategy centers around primary, secondary, and tertiary prevention of opioid addiction.
- Primary prevention: seeks to reduce the risk of TennCare members progressing to opioid addiction or dependence. This level of prevention centers around TennCare members who are new or non-chronic users of opioids.
- Secondary prevention: seeks to reduce the impact of opioid use for TennCare members by engaging in early detection and intervention. This level of prevention centers around TennCare members who are women of childbearing age, as well as of TennCare providers.
- Tertiary prevention: seeks to provide evidence-based addiction recovery supports for TennCare members with opioid dependence or misuse.
As noted, a significant component of TennCare’s opioid strategy involves establishing a high-quality Substance Use Disorder (SUD) and Opioid Use Disorder (OUD) treatment network for members. To accomplish this, TennCare focused on four key milestones:
- Establishing a Medications for Opioid Use Disorder (MOUD) program description and quality standards;
- Building access to and capacity for a high-quality provider network across the care spectrum;
- Increasing the coordination of care and clinical integration; and
- Identifying opportunities for value-based interventions within a high-quality OUD and SUD treatment network.
Coverage of Opioids
TennCare contracts with a Pharmacy Benefit Manager (PBM) to administer the TennCare pharmacy benefit. As part of the contract agreement with the PBM and at the direction of TennCare, the PBM implements and operationalizes point-of-sale (POS) edits at the time a prescription is processed at the pharmacy. The process of implementing POS edits has been iterative over the years to ensure the best outcomes for our members and has focused on evidenced based practices and safe utilization of opioid prescriptions. TennCare has a coverage benefit limit in place for both short and long-term opioids prescriptions that follows CDC chronic pain guidelines.
- Since 2017, TennCare has followed CDC chronic pain guidelines for long-term opioid prescriptions with limited exceptions for specified clinical conditions
- Since 2018, TennCare has implemented limits in dose and duration for short-term opioid use
- TennCare developed the Preferred Drug List (PDL) to prevent misuse of opioids and other controlled substances
Proactive Engagement of Women of Childbearing Age
TennCare partners with the Managed Care Organizations (MCOs) and the Pharmacy Benefits Administrator (PBA) to use data analytics to identify potential clinical risk for women of childbearing age using opioids. This model uses risk stratification to identify and stratify members into different severity categories which include risk groupings such as those at high risk for developing opioid addiction or opioid use disorder. The MCOs use information from the model to provide appropriate forms of member engagement, outreach, and possible intervention.
Provider Education
TennCare’s managed care organizations offer annual webinars focused on enhancing provider knowledge and skills to promote early engagement and risk mitigation for vulnerable populations. Continuing education units are offered to providers for participation in BESMART webinars. See Provider Education for recent educational opportunities.
Treatment of Individuals with Opioid Use Disorder
TennCare covers a variety of treatment options for individuals with opioid use disorder including withdrawal management and medications for opioid use disorder at inpatient, residential, and outpatient levels for substance use disorder and opioid use disorder.
Buprenorphine Enhanced Supportive Medication Assisted Recovery and Treatment (BESMART) Program
BESMART was developed in 2018 to be a specialized provider network developed by each Managed Care Organization focused on contracting with high quality medications for opioid use disorder (MOUD) providers to provide comprehensive care to TennCare members with opioid use disorder (OUD).
Want to become a BESMART provider? See Office-based Buprenorphine Treatment.
Since its implementation in 2018, TennCare’s opioid strategy has demonstrated a significant impact on both members and providers.
TennCare Acute and Chronic Opioid Users
Overall, the number of TennCare new, acute opioid users has declined by 55% since 2015. The largest decrease occurred following the implementation of new TennCare opioid benefit limits.
TennCare Prescription Patterns for Acute Opioid Use
81% of all first time and acute opioid users are now receiving 6 days or less of opioids after new limits implemented. This reduction in the days of supply for opioids for members decreases the likelihood for developing addiction.
Neonatal Abstinence Syndrome
The rate of neonatal abstinence syndrome (also known as neonatal opioid withdrawal syndrome) births among TennCare recipients has decreased for several successive years and remained stable over the past three years. Further information is available in the annual NAS report.
