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Work Comp PBMs – it’s drug trend report time

Today’s post is authored by Jack Johnston who is spending his summer interning at Health Strategy Associates; Jack is going to be a senior at Syracuse University (my alma mater); he’s studying Health and Exercise Science.

The three largest PBMs have sent out their annual drug trend reports to tell the Workers’ Comp world what’s been going on this past year.  Instead of you having to read through each entire report and finding out what’s new, I’ve bit the bullet and gone through them for you.  Coventry-First Script, Progressive Medical-PMSI, and Express Scripts have all made much progress and developed new ways to further develop their success.  Let’s give you the skinny…

PBM Goals:

Coventry-First Script has been working with physicians to eliminate the use of narcotics  – due primarily to widely known potential for misuse.  Increasing generic brand utilization to lower costs and helping the older workforce remain healthy enough to work have also been other tasks Coventry’s been working on.

Progressive has managed to accomplish their goal to decrease opioid usage by working with physicians, prescribers, and injured workers.  Progressive Medical is working to ensure injured workers will return to work healthy, as soon as possible, while employers (payers) are getting the lowest possible costs.

Express Scripts is focused on reducing drug costs, utilization, and abuse for workers and prescribers while increasing the use of more affordable generic medication wherever possible.

Summary Findings:

With all three PBMs reporting that OxyContin is once again the most prescribed drug (in terms of dollars) on the market, they’ve been working on ways to decrease the use of opioids.  Progressive reported a 5.0% decrease in opioid usage while Express also showed a decrease of 3.0%.  Progressive also reported that the opioid cost per claim dropped by 6.0% and the workers who were prescribed opioid analgesics this past year used lower dosages compared to 2012; with MEDs diminishing by 9.6% over the year as well.  (First Script did not show any indication of an opioid usage % decrease in their report) correction – First Script indicated utilization per claimant decreased 9.1%, the biggest decline among the three PBMs.

Progressive is using a “Multiple Prescriber Service” to identify injured workers that are getting drugs from more than one prescriber.  With the main focus on multiple opioid prescribers, Progressive notifies all prescribers treating the injured worker and offers guidance to address the issue.

Express Scripts’ MED Management Program allows clients to set max levels for the amount of narcotic medication prescriptions an injured worker can fill.  Once the amount is exceeded, the program employes a review process before additional medication is dispensed. According to Express, the MED Management Program has successfully reduced drug abuse, limited addiction, and controlled costs.

Express has also continued to developed their Physician Outreach Program to encourage the use of generics, which appears to be Express’s main concern.

The First Script network pharmacies are being re-credentialed under stricter requirements including background checks and site audits to ensure legitimate dispensing practices.  The network also blocks narcotics and other controlled substances through mail service to prevent potential drug overdose, diversion, and misuse.  This reduces risk to the patient and the community.


  • Opioid use is the main focus of these PBMs.
  • PBMs are having success with decreasing opioid usage through a variety of targeted programs.

What Does This Mean For You?

  • Claimants have a lesser chance to become addicted to their medications (Yay!).
  • Medication costs have lowered over the years.
  • If you’re not using a PBM, sign up and reap the benefits!

4 thoughts on “Work Comp PBMs – it’s drug trend report time”

  1. Have the PBM’s expressed any opinion on States i.e. Texas, Oklahoma, adopting closed formularies to further manage prescription usage?

    1. not to my knowledge, however it is clear the TX formulary has had a significant impact on prescribing, and that has been a great help to PBMs trying to reduce opioid overuse.

  2. note: Oxycontin is the #1 by total spend; hydrocodone-APAP products are the number one by volume.

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Joe Paduda is the principal of Health Strategy Associates




A national consulting firm specializing in managed care for workers’ compensation, group health and auto, and health care cost containment. We serve insurers, employers and health care providers.



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