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Update: High Risk Medications for Seniors

(Please note the following update to original 12/11/13 article, which appears below in its entirety.)

Starting in 2014, brand and generic medications that the Centers for Medicare & Medicaid Services consider to be high risk for patients ages 65 and older may be covered on a higher copayment tier.  If you prescribe a high-risk medication (see chart below in original article) for your Blue MedicareSM patients who are 65 or older, you may be asked to complete a prior authorization form in order for the medication to be considered for coverage.  For more complete information, please refer to the Medicare formulary online at

(Original article from 12/11/13)

Are you prescribing high-risk medications to your patients who are over the age of 65? Many of our Blue MedicareSM members are receiving high-risk medications as part of their routine treatment plan. High-risk medications are those identified by AGS Beers Criteria and by the Pharmacy Quality Alliance that tend to cause adverse drug events in older adults due to their pharmacologic properties and the physiologic changes of aging. According to Blue Cross and Blue Shield of North Carolina (BCBSNC) prescription drug claims, the skeletal muscle relaxants indomethacin and hydroxyzine are among the most prescribed medications on a list of drugs that should be avoided in elderly patients.

BCBSNC would like to work with providers to avoid prescribing drugs considered high risk for our members over the age of 65, especially when there may be safer alternatives. Both the Centers for Medicare & Medicaid Services (CMS) and the Healthcare Effectiveness Data and Information Set (HEDIS) have quality measures that focus on decreasing the use of high-risk medications in the elderly. The CMS measure is defined as the percentage of members receiving more than two prescription fills of a high-risk medication. For this measure, a lower percentage is better.

The following sleep medications, non-benzodiazepine hypnotics such as zolpidem, lunesta, or sonata, are also on the high-risk medication list and are recommended for short-term use of less than 90 days due to potential side effects in seniors.

The table below is adapted from information included on the 2012 AGS Beers Criteria of Potentially Inappropriate Medication Use in Older Adults. For a more complete listing, please refer to the website



Potential Alternatives







Skeletal Muscle Relaxants:

Anticholinergic side effects: worsened cognition & behavioral problems (especially in dementia); urinary retention OR incontinence; confusion; sedation; weakness; questionable efficacy (at lower doses)


Non-pharmacologic treatment:


Baclofen, tizanidine



Older Antihistamines:

Anticholinergic side effects: worsened cognition & behavioral problems (especially in dementia); urinary retention OR incontinence; confusion; enhanced sedation

For itching

triamcinolone cream 0.025% or OTC emollients


For allergic rhinitis:

nasal steroid sprays, or low-sedating antihistamines such as levocetirizine or OTC loratadine or cetirizine





Oral Estrogens:

Increased risk of breast and/or endometrial cancer; NOT cardioprotective in older women


Oral Estrogens

Increased risk of cardiovascular disease, cancer and cancer-related death




Menopause symptoms :

Evaluate appropriateness of ongoing therapy. Use lowest effective dose for the shortest amount of time.

Vaginal symptoms:

vaginal estradiol (cream, tab, ring);

vaginal conj estrogen cream

Zolpidem,zaleplon, Lunesta

Non-benzodiazepine hypnotics

Avoid chronic use  >90 days

Non-pharmacologic treatment :

Sleep hygiene; cognitive behavior therapy





Increases risk of GI bleeding/peptic ulcer diseases  in  hisk risk groups


Non-pharmacologic treatment:


Naproxen, ibuprofen, sulindac, Voltaren Gel





Potentially less effective with compromised renal function. Increased risk of pulmonary toxicity


Trimethoprim/sulfamethoxazole DS



A complete list of high-risk medications and their impact on CMS star ratings can be found on the Pharmacy Quality Alliance website at

BCBSNC is committed to providing the most appropriate medications to our Medicare members to enhance their safety. We ask providers to carefully evaluate whether any of the high-risk medications on this list are still appropriate for your older patients and to consider appropriate alternatives. This may involve a frank discussion with your patients about risks and benefits.  As the prescriber, you are the key advocate in helping patients decide which medications they need and which therapies represent the least risk as they age.