Medicare Part D Opioid Safety Alerts

As the nation continues to battle the opioid epidemic, CMS has implemented new Medicare Part D opioid policies in 2019. These new policies make pharmacists responsible for identifying potential risks and relaying that information to prescribers. The following safety alerts will be applied to specific opioid prescriptions:

  • Seven day supply limit for opioid naïve patients: Patients who have not filled an opioid prescription in the past 60 days will be limited to a seven day supply on a new opioid prescription. A hard edit will stop the pharmacy from processing these prescriptions without an override or authorization from the plan. Prescribers can request a coverage determination in advance if they believe patients will need a longer course of treatment. Prescribers are encouraged to re-assess the patient before prescribing additional opioid therapy following the seven day course of treatment. The goal is to limit opioid use for acute pain.
  • Opioid care coordination alerts: When a patient presents one or more opioid prescriptions resulting in a cumulative morphine milligram equivalent (MME) greater than or equal to 90 MME per day, an alert will be triggered at the pharmacy. The pharmacist should contact the prescriber to confirm intent and document the discussion before entering an override code. Plans have the option to implement a hard edit at a cumulative 200 MME per day. The goal of these care coordination safety alerts is to make prescribers aware of patient opioid usage, especially when patients see multiple prescribers.

Health plans, prescribers, and pharmacies will need to work together to ensure patients are receiving adequate pain management treatment while limiting the potential for opioid abuse.  PHSI also expects the Medicare Part D safety alerts to become standard offerings in the commercial sector.

Additional information and resources for patients, prescribers, and pharmacists is available at https://www.cms.gov/medicare/prescription-drug-coverage/prescriptiondrugcovcontra/rxutilization.html.

 

Published February 2019

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