New Opioid Drug Management Program for Medicare Members

Jan. 08, 2019

On January 1, 2019, BCBSMT implemented a new opioid drug management program to promote the safe and effective use of prescription opioids for our Medicare Part D members who have prescription drug benefits administered through Prime Therapeutics.

Similar to the Appropriate Use of Opioids program that was implemented August 2018 for our non-Medicare members, this new program includes improved point-of-sale safety alerts and drug management programs to better coordinate care when chronic high-risk opioid use is present. These new policies are aimed to improve identification and better manage potential opioid misuse.

Elements in the program also follow safety guidelines as recommended by the Centers for Disease Control and Prevention (CDC), the Centers for Medicare and Medicaid (CMS) and other nationally recognized guidelines. Some of the program highlights include:

  • 7 Day Supply Limit for Opioid Naïve Patients

    An initial supply of prescription opioids may be limited to a supply of 7 days or less for an opioid naïve patient. A member is considered “opioid naïve” if they have not filled an opioid prescription (long-acting or short-acting) within the past 90 days.

    • Members may not be subject to this program criteria if:
      • There is claim history that the member is currently being treated with opioid therapy within the past 90 days OR
      • The health care provider states the member is currently being treated with opioid therapy OR
      • The member is being treated for active cancer-related pain OR
      • The member is being treated for sickle cell disease-related pain OR
      • The member is residing in a long-term care facility OR
      • The member is in hospice care or receiving palliative (end-of-life) care
    • The dispensing pharmacist can contact the number on the member ID card to assist in these situations. Members or their health care provider can also call.
  • Opioid Care Coordination Alert

    There may be a limit on the cumulative daily Morphine Milligram Equivalent (MME) reported. The MME is calculated across the submitted claim and selected historical claims. This point-of-sale edit may deny claims that exceed a threshold for maximum number of prescribing health care providers and maximum number of pharmacies dispensing opioid prescriptions.

    • The dispensing pharmacist may consult with the health care provider and, if the prescription is deemed appropriate, may enter an override. Please be aware that on-call staff may receive outreach from pharmacies regarding this MME limit. Please ensure your staff are educated on the importance of responding timely to these inquiries.
  • Additional Opioid Safety Edits for Possible Duplicate or Key Potentiator Drugs

    Additional safety edits will alert pharmacists at the point-of-sale about members who may be taking duplicate or key potentiator drugs, such as duplicate long-acting opioids or concurrent opioid and benzodiazepine use.

    • The dispensing pharmacist may be able to enter an override for these edits if the prescription is deemed appropriate. They also may consult with health care providers when needed.

The new policies are not intended as prescribing limits, but as tools to better alert health care providers of potential opioid misuse or abuse. Providers and members may request a coverage determination for MME exceptions if necessary and appropriate. Please be aware that providers and on-call staff may receive urgent outreach from pharmacies regarding these edits. Please ensure all staff is educated on the importance of responding timely to these inquiries.

This information is for informational purposes only and is not intended to replace your clinical judgement. Pharmacy benefits and limits are subject to the terms set forth in the member’s certificate of coverage. Only you, in direct consultation with your patient, can determine your patient’s drug therapy, regardless of the member’s benefits.

Prime Therapeutics is a separate pharmacy benefit management company contracted by BCBSMT to provide pharmacy benefit management and other related services. BCBSMT, as well as several Blue Cross and Blue Shield Plans, has an ownership interest in Prime Therapeutics.