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 use is present.
Real-Time Safety Alerts at the Time of Dispensing
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 - limit initial dispensing to a supply of 7 days or less. However, if a prescriber believes that a patient will need more than a 7 day supply initially, the provider can proactively request a coverage determination on behalf of the patient attesting to the medical need for a supply greater than 7 days. Additionally, if a provider assesses upon re-evaluation that a patient will need additional opioid therapy, subsequent prescriptions will not be subject to the 7 day supply limit.
- Opioid care coordination alert – a threshold of cumulative morphine milligram equivalent 90 MME per day. This safety alert identifies potentially high risk patients who may benefit from closer monitoring and care coordination. 90 MME is cited in the CDC Guideline as the level above which prescribers should generally avoid. Although this is not a prescribing limit.
Drug Management Programs
The potential tools include:
- Patient-specific point of sale (POS) claim edit: individualized POS edit limits the amount of frequently abused drugs that may be dispensed to the patient. The plan will make every effort to obtain a prescriber’s agreement for this limitation, but is authorized to implement it if no prescriber responds to the plan’s attempts at contacting the prescriber through case management.
- Pharmacy limitation (also known as “pharmacy lock-in”): This limitation will require the patient to obtain prescriptions for frequently abused drugs at a certain pharmacy(ies). The plan must verify with a prescriber that the patient is at-risk, but is not required to obtain a prescriber’s agreement to the limitation.
- Prescriber limitation (also known as “prescriber lock-in”): A limitation that will require the patient to obtain their prescriptions for frequently abused drugs from a certain prescriber(s). The plan must obtain the prescriber’s agreement to be a prescriber and confirm the prescriber’s selection for this limitation.
Full guide available: here