New Medicare Part D Opioid Policies Effective January 2019

 

CMS is implementing new opioid policies for Medicare drug plans. Providers are in the best position to identify and manage potential opioid over utilization in the Medicare Part D population. Medicare prescription drug plans can assist providers by alerting them about unusual utilization patterns in prescription claims.

Specific to prescription opioids, beginning in January 2019, Medicare Part D plans will employ the following new safety alerts at the pharmacy:


Seven (7) day supply limit for opioid naïve patients. 
Part D plans are expected to implement a hard safety edit to limit initial dispensing to a supply of seven days or less. A hard safety edit stops the pharmacy from processing a prescription until an override is entered or authorized by the plan. This policy will affect Medicare patients who have not filled an opioid prescription recently (for example, within the past 60 days) when they present a prescription at the pharmacy for an opioid pain medication for greater than a seven day supply.

Opioid care coordination alert.
This policy will affect Medicare patients when they present an opioid prescription at the pharmacy and their cumulative morphine milligram equivalent (MME) per day across all of their opioid prescription(s) reaches or exceeds 90 MME. 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. It is the prescriber who writes the prescription that triggers the alert who will be contacted by the pharmacy even if that prescription itself is below the 90 MME threshold.

Seven (7) day supply limit for opioid naïve patients.
Part D plans are expected to implement a hard safety edit to limit initial dispensing to a supply of seven days or less. A hard safety edit stops the pharmacy from processing a prescription until an override is entered or authorized by the plan. This policy will affect Medicare patients who have not filled an opioid prescription recently (for example, within the past 60 days) when they present a prescription at the pharmacy for an opioid pain medication for greater than a seven day supply.

Opioid care coordination alert.


This policy will affect Medicare patients when they present an opioid prescription at the pharmacy and their cumulative morphine milligram equivalent (MME) per day across all of their opioid prescription(s) reaches or exceeds 90 MME. 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. It is the prescriber who writes the prescription that triggers the alert who will be contacted by the pharmacy even if that prescription itself is below the 90 MME threshold.

>> CMS has posted new training materials and tip sheets.

Seven (7) day supply limit for opioid naïve patients. 
Part D plans are expected to implement a hard safety edit to limit initial dispensing to a supply of seven days or less. A hard safety edit stops the pharmacy from processing a prescription until an override is entered or authorized by the plan. This policy will affect Medicare patients who have not filled an opioid prescription recently (for example, within the past 60 days) when they present a prescription at the pharmacy for an opioid pain medication for greater than a seven day supply.

Opioid care coordination alert.
This policy will affect Medicare patients when they present an opioid prescription at the pharmacy and their cumulative morphine milligram equivalent (MME) per day across all of their opioid prescription(s) reaches or exceeds 90 MME. 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. It is the prescriber who writes the prescription that triggers the alert who will be contacted by the pharmacy even if that prescription itself is below the 90 MME t