The Centers for Medicare and Medicaid Services (CMS) finalized new opioid policies for Medicare drug plans starting on January 1, 2019. CMS is dedicated to helping individuals who are eligible for Medicare to use prescription opioid pain medications more safely. CMS feels providers are in the best position to identify and manage potential opioid overutilization in the Medicare Part D population. The new policies include improved safety alerts when opioid prescriptions are dispensed at the pharmacy and drug management programs for patients determined to be at-risk for misuse or abuse of opioids or other frequently abused drugs.
Residents of long-term care facilities, in hospice care, patients receiving palliative or end-of-life care, and patients being treated for active cancer-related pain are exempt from these new interventions. These policies should not impact patients’ access to medication-assisted treatment (MAT), such as buprenorphine.
To comply with the new Medicare opioid policies, Mercy Care Advantage (MCA) implemented point of sale safety edits and a Drug Management Program (DMP) on January 1, 2019. This program includes system generated safety edits and a safety review at the point of sale when members are at the pharmacy filling opioid or benzodiazepines prescriptions and will include the following types of reviews:
- Potentially unsafe opioid amounts.
- Taking opioids with benzodiazepines like Xanax®, Valium®, and Klonopin®.
- New opioid use (opioid naïve) will be limited to a 7-day supply or less. This edit is not applicable to individuals already taking opioids.
- Concurrent use of 2 Long Acting opioids.
- Use of a Long Acting opioid without first trying a Short Acting opioid.
These reviews are especially important if a member has more than one doctor who prescribes these drugs. In some cases, the pharmacist may contact providers about the need for the medication and that they are being used safely before dispensing the medication. In some instances the pharmacist will be able to able to determine if the safety edit should be overridden. When an opioid safety edit is triggered and the issue cannot be resolved at point of sale by the pharmacist, they will give members a copy of the notice “Medicare Prescription Drug Coverage and Your Rights”. This notice explains the members right to ask for a coverage determination. Providers may also request cover determinations for members in this situation.
Case Management & Limiting Access to Certain Part D Drugs
Under the new Drug Management Program (DMP) policies, CMS will provide Plans with quarterly Overutilization Monitoring System (OMS) reports of potential at-risk beneficiaries (PARBs). MCA will use this information and also identify members by applying the CMS criteria to engage in case management for identified members. An at risk beneficiary (ARB) is a member who meets the OMS criteria, is not exempted from DMP, and is identified to be “at-risk beneficiary” by the MCA Drug Management Program.
The goal of case management under a DMP is to achieve a consensus among multiple prescribers as to the appropriate, medically necessary, and safe dosage of frequently abused drugs (FADs), and if there is no consensus, to facilitate one. MCA must gather information and opinions from the prescribers in writing and verbally, as necessary, about any factors in the member’s treatment that are relevant to a determination whether the member is an ARB, such as:
- whether the member would be considered as an exempted
- whether the prescribed medications are appropriate, medically necessary, and safe for the member’s medical conditions
- any other relevant treatment factors
- agreement, if necessary, as to whether a limitation on the member’s access to coverage of FADs is warranted for the safety of the member
Once case management is completed if it’s determined that a member’s use of prescription opioids and benzodiazepines isn’t safe, MCA will be able to limit coverage for these drugs.
Under the Drug Management Program MCA can implement the following limitations:
- A point-of-sale claim edit for FADs that is specific to an at risk beneficiary (ARB)
- Require member to get their medications from only certain doctors or pharmacies to help better coordinate care
If MCA determines a member requires access limitations to frequently abused drugs, MCA is required to provide 30-day advance written notice to the member and providers. The coverage limitation may be put in place for 12 months and extended for an additional 12 months (total of 24 months). If MCA decides to limit coverage under the DMP, the member and their prescriber have the right to appeal the plan’s decision.
As always, don't hesitate to contact your Mercy Care Provider Relations Representative with any questions or comments. You can find this notice and all other provider notices on our
Mercy Care website
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