2019 Medicare Part D Opioid Policies: Information for Prescribers

2019 Medicare Part D Opioid Policies

CMS announced new strategies to further help Medicare Part D plan sponsors prevent and combat prescription opioid overuse by tailoring its approach to help distinct populations of Medicare Part D opioid users including:

  1. New opioid users (opioid naïve)
  2. Chronic opioid users
  3. Opioid users with potentially problematic concurrent medication use (e.g., opioids taken with benzodiazepines—like Xanax, Valium, Klonopin—can increase risks for addiction, overdose, and death.)

CMS encourages prescribers to respond to pharmacists’ outreach in a timely manner and give the appropriate training to on-call prescribers when necessary to resolve opioid safety edits expeditiously and avoid disruption of therapy.

Part D plans are expected to implement safety alerts (pharmacy claim edits) for pharmacists to review at the time of dispensing the medication to prevent unsafe utilization of drugs.  QHPNY will implement the following opioid safety edits at the point-of-sale (POS) in 2019:

  1. Soft edit for concurrent opioid and benzodiazepine use
  2. Soft edit for duplicative long-acting (LA) opioid therapy
  3. Care coordination edit at 90 morphine milligram equivalents (MME) (soft edit)
  4. Hard edit at 200 MME
  5. Hard edit 7-day supply limit for initial opioid fills (opioid naïve patients)
Opioid Safety Alert / Description

Seven-day supply limit for opioid naïve patients
(“hard edit”)

Medicare Part D patients who have not filled an opioid prescription within the past 60 days will be limited to a supply of 7 days or less.

Limiting the amount dispensed with the first opioid prescription may reduce the risk of a future dependency or over of these drugs.

Important note: This alert should not impact patients who already take opioids.

Prescriber’s Role
  • Patient may receive up to a 7-day supply OR request a coverage determination for full days’ supply as written.
  • The prescriber has the right to request a coverage determination on patient’s behalf, including the right to request an expedited or standard coverage determination in advance of prescribing an opioid.
  • The prescriber only needs to attest to plan that the day supply is the intended and medically necessary amount.
  • Subsequent prescriptions written by prescribers are not subject to the 7-days supply limit, as the patient will no longer be considered opioid naïve.

Opioid care coordination alert at 90 morphine milligram equivalent (MME) (“soft edit”)

This policy will affect Medicare patients when they present an opioid prescription at the pharmacy and their cumulative MME per day across all of their opioid prescription(s) reaches or exceeds 90 MME.

The prescriber will be contacted to resolve the alerts and to be informed of other opioid prescribers or increasing level (MME) of opioids.

Important Note: This is not a prescribing limit. Decisions to taper or discontinue prescription opioids are individualized between the patient and prescriber.

  • Regardless of whether individual prescription(s) are written below the threshold, the alert will be triggered by the fill of the prescription that reaches the cumulative threshold of 90 MME or greater.
  • The prescriber who writes the prescription that triggers the alert will be contacted even if that prescription itself is below the 90 MME threshold.
  • Once a pharmacist consults with a prescriber on a patient’s prescription for a plan year, the prescriber will not be contacted on every opioid prescription written for the same patient after that unless QHPNY implements further restrictions.
  • On the patient’s behalf, the physician or other prescriber has the right to request a coverage determination for a drug(s), including the right to request an expedited or standard coverage determination in advance of prescribing an opioid.

Concurrent opioid and benzodiazepine use (“soft edit”)

OR

Duplicative long-acting opioid therapy (“soft edit”)

Alerts will trigger when opioids and benzodiazepines are taken concurrently OR if multiple duplicate long-acting opioids are detected.

  • The pharmacist will conduct additional safety reviews to determine if the patient’s opioid use is safe and clinically appropriate.
  • The prescriber may be contacted.

Safety Alert at 200 MME (“hard edit”)

Some plans may implement a hard safety alert when a patient’s cumulative opioid daily dosage reaches 200 MME or more.
Important Note: This is not a prescribing limit. Decisions to taper or discontinue prescription opioids are individualized between the patient and prescriber.

  • This alert stops the pharmacy from processing the prescription until an override is entered or authorized by QHPNY.
  • On the patient’s behalf, the physician or other prescriber has the right to request a coverage determination for a drug(s), including the right to request an expedited or standard coverage determination in advance of prescribing an opioid.
  • In the absence of other approved utilization management requirements, once the prescriber(s) attests that the identified cumulative MME level is the intended and medically necessary amount, the medication will be dispensed to the patient.

Soft edit – rejection may be resolved by the pharmacist at the point-of-service (without QHPNY assistance)

Hard edit – rejection may only be resolved via utilization review interactions between QHPNY, the pharmacy, the physician/prescriber

**Note** Residents of long-term care facilities, those in hospice care, patients receiving palliative or end-of-life care, and patients being treated for active cancer-related pain are exempt from these interventions.  These policies should not impact patients’ access to medication-assisted treatment (MAT), such as buprenorphine.

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