As one of the largest payers of healthcare services, the Centers for Medicare & Medicaid Services (CMS) plays a central role in addressing the opioid epidemic.
CMS is focusing on three key areas—prevention, treatment and data. To target these key areas, CMS is implementing new opioid policies for Medicare drug plans. These policies involve further partnership with providers and prescription drug plans. Providers are in the best position to identify and manage potential opioid overutilization 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:
- 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 7 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 7 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 posted new training materials, including slide decks and tip sheets for:
CMS also recently released an MLN Matters® Article: A Prescriber’s Guide to the New Medicare Part D Opioid Overutilization Policies for 2019. Visit the Reducing Opioid Misuse webpage for more information on CMS’ overall strategy.
“Great Plains QIN is responding to the opioid epidemic by promoting and sharing important CMS updates and policy changes. The new policies include improved safety alerts when opioid prescriptions are dispensed at the pharmacy and drug management programs to better coordinate care when chronic high-risk opioid users present. These new policies go into effect January 1, 2019.” states Tammy Baumann, RN, LSSGB, CADDCT, CDP, Great Plains QIN Quality Improvement Advisor.
Visit the Great Plains QIN Medication Safety page for additional resources and learning opportunities.