How a Clinical Mailer Helped Cut Dangerous Drug Combinations Ahead of New CMS Star Ratings Measures

Authors: Scott Weber, PharmD; Agata Siwak, PharmD, MSBA; Alex J. Stuhl, MSBA; Courtney Kapitz, PharmD; Mandy Deschaine, MS; Marnie Wickizer, PharmD, MBA, CDCES

Many Medicare patients end up on five, six or more prescriptions long before anyone stops to ask whether the combination still makes sense. Each drug gets added one at a time, often by a different doctor, to treat a real and current problem: a new diagnosis, a new symptom, a new specialist’s recommendation. On its own, each prescription can be entirely appropriate. Layered together over months or years, the combination of multiple drugs, or polypharmacy, can raise the risk of falls, confusion, slowed breathing and hospital visits that no single prescriber ever intended. Health plans are often aware of this problem, but can struggle to catch it early, cheaply and quickly enough to reach every patient.

The Centers for Medicare & Medicaid Services (CMS) built its own approach to try and reduce complications with two new Medicare Part D Star Ratings measures — Polypharmacy: Use of Multiple Anticholinergic Medications in Older Adults (POLY-ACH) and Concurrent Use of Opioids and Benzodiazepines (COB).¹ Both take effect with the 2027 Star Ratings, using 2025 measurement-year claims data. And both come with a catch: once a member’s claims cross the measure’s inclusion threshold, that member stays counted for the rest of the calendar year, even if a prescriber fixes the problem before the year ends. The only way to move the number is to intervene before a patient crosses the line.

Navitus Health Solutions built its response several years before CMS added Poly-ACH and COB as official Star measures. CMS rolls out new Star measures as “display measures” first, publishing plan-level data without tying it to the quality bonus payments that come with a strong Star Rating. The Government Clinical Services team at Navitus was already tracking Poly-ACH and COB as display measures and used that lead time to build a prescriber-facing mailing program so it would already be running once the measures started to count.

The challenge with these classes of medications is that adverse side effects can easily stack up, creating more risk than a single prescription. Anticholinergic side effects, including drowsiness, confusion and impaired coordination, run across many common drug classes, including antihistamines, certain antidepressants, antipsychotics and overactive-bladder medications. A patient can be appropriately prescribed each one and still build up a dangerous load, especially when different specialists write each prescription without seeing the full list. For older patients served by Medicare, side effects that cause issues with balance or confusion can be especially risky and create new long-term medical issues after a simple slip or fall. 

Opioid-benzodiazepine combinations carry a similar but sharper risk: the US Food and Drug Administration (FDA) added its boxed warning to both drug classes in 2016 after finding the combination raises the risk of profound sedation, respiratory depression, coma and death². And a 2018 analysis of Medicare Part D beneficiaries found concurrent use raised the risk of opioid-related overdose.³

The Navitus clinical program identified members through a four-month claims lookback, flagging patients with cumulative overlapping days’ supply of anticholinergic, opioid, or benzodiazepine prescriptions, indicating that members were taking more than two drugs in the same class that could cause overlapping side effects. The program looked at each POLY-ACH and COB cohort separately, but also created specific outreach for patients who were taking both classes of anticholinergic medications, and opioids in combinations with benzodiazepines. 

Each flagged member’s prescribers received a letter explaining the safety concern, a copy of that member’s relevant medication profile and a suggestion to review the regimen for safer alternatives. The letter explicitly states that the decision belongs to the prescriber: stopping an opioid or benzodiazepine abruptly can trigger withdrawal, so any change has to account for the patient’s full clinical picture.

A pilot cohort tested how much impact a single letter could have. Members flagged from an August-to-November 2024 claims lookback received a mailing in December 2024; a second cohort, flagged from an October 2024-to-January 2025 lookback, received a mailing in February 2025. After just the first mailing, 49.5% of the 100 POLY-ACH members and 30.3% of the 99 COB members fell back below the qualifying threshold. This is according to results presented at the 2026 AMCP Annual Meeting, where the study was selected out of more than 450 posters in the Best Poster competition for the Residency/Fellowship category.⁴ The gap tracks with what’s already known about deprescribing: swapping out an antihistamine or bladder medication is simpler than tapering an opioid or benzodiazepine, which takes a slower, supervised process to avoid withdrawal.

That was one letter’s effect on a 199-member pilot. Navitus has since kept the mailing running quarterly for the same population, expanding outreach to more patients with overlapping days of medication. Year-over-year tracking across that broader group now shows roughly 22% of flagged POLY-ACH members and 6% of flagged COB members exiting the cohort, an overall rate near 14%. The company has also broadened its inclusion criteria to flag members earlier, before they build up as much overlapping days’ supply, based on the idea that catching the problem sooner makes deprescribing easier.

By simply reminding prescribers of all the similar medications a patient was taking, no matter which clinician prescribed them, doctors and patients were able to meet these CMS requirements and potentially reduce dangerous side effects without having to enlist case managers, conduct home visits or create a new benefit design. A letter sent to the right prescriber at the right time, with the right patient’s medication list attached, moved a real share of high-risk Medicare beneficiaries off dangerous drug combinations before those combinations could count against a single Star Rating. By efficiently bringing more transparency into multimedication treatment plans for Medicare patients, the program was able to reduce drug costs and improve patient safety. 

About the Authors

Scott Weber, PharmD, is a utilization management pharmacist with Archimedes, part of Navitus Health Solutions. He led the statistical analysis behind the company’s POLY-ACH and COB deprescribing pilot as a pharmacy resident.

Courtney Kapitz, PharmD, is manager of government clinical services at Navitus Health Solutions, where she oversees the pharmacist team that designed and administers the mailing program the pilot studied along with other clinical services for the Medicare and Medicaid population.

Agata Siwak, PharmD, MSBA, is a manager in clinical outcomes analysis at Navitus Health Solutions, where she leads outcomes research and analytics initiatives focused on managed care pharmacy, real-world evidence and quality improvement.

References

1. Centers for Medicare & Medicaid Services. Medicare program; changes to the Medicare Advantage and the Medicare Prescription Drug Benefit Program for contract year 2024 – remaining provisions and contract year 2025 policy and technical changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, Medicare Cost Plan Program, and Programs of All-Inclusive Care for the Elderly (PACE): final rule. Federal Register. 2024;89(79):30448-30848.

2. US Food and Drug Administration. FDA Drug Safety Communication: FDA warns about serious risks and death when combining opioid pain or cough medicines with benzodiazepines; requires its strongest warning [internet]. 2016 [cited 2016 Nov 9]. Available at: Drug Safety and Availability, ucm518473.htm. 

3. Hernandez I, He M, Brooks MM, et al. Exposure-response association between concurrent opioid and benzodiazepine use and risk of opioid-related overdose in Medicare Part D beneficiaries. JAMA Netw Open. 2018;1(2):e180919. doi:10.1001/jamanetworkopen.2018.0919

4. Weber SA, Siwak A, Stuhl AJ, Kapitz C, Deschaine M, Wickizer M. An analysis of a polypharmacy deprescribing program for anticholinergics and concurrent opioid and benzodiazepine usage for Medicare beneficiaries: a pilot initiative. Poster presented at: Academy of Managed Care Pharmacy (AMCP) 2026 Annual Meeting; April 2026; Nashville, TN. https://www.lumicera.com/wp-content/uploads/2026/03/An-Analysis-of-a-Polypharmacy-Deprescribing-Program-for-Anticholinergics-and-Concurrent-Opioid-and-Benzodiazepine-Usage-for-Medi.pdf