CMS releases 2019 opioid safety edits

In the final contract year 2019 Call Letter, the Centers for Medicare & Medicaid Services announced strategies to further help Medicare Part D plan sponsors prevent and combat prescription opioid overuse. CMS has tailored its approach to help Medicare Part D opioid users, including new or opioid naïve users, chronic opioid users and those with potentially problematic concurrent medication use.

CMS’ opioid safety edits are intended to encourage both prescribers and members to actively think about and discuss overdose risks and prevention. Residents of long-term care facilities, those in hospice care, patients receiving palliative or end-of-life care, and patients being treated for active cancer-related pain are exempt from these interventions. Buprenorphine for medication-assisted treatment isn’t included in the opioid safety edits.

CMS expects sponsors to implement the following edits beginning Jan. 1, 2019:

1. Soft edit for concurrent opioid and benzodiazepine use
   
   
1. Soft edit at the point of sale to prompt additional safety review when these agents are used concurrently.
   
   
2. If the opioid or benzodiazepine is written by the same prescriber, this edit will not generate. If the prescriptions are written by different prescribers, the edit will generate.
   
   
2. Soft edit for duplicative long-acting opioid therapy
   
   
1. Soft edit at the point of sale to prompt additional safety review when a member is receiving multiple long-acting opioids.
   
   
2. Any usage of multiple long-acting opioids, even if prescribed by the same provider, will generate this edit.
   
   
3. Care coordination edit at 90 morphine milligram equivalents
   
   
1. The care coordination edit will trigger when a member’s cumulative MME per day across their opioid prescriptions reaches or exceeds 90 MME, and there are at least two prescribers contributing to the edit.
   
   
2. The pharmacist must consult the prescriber and document the discussion and, if the prescriber confirms medical necessity, use an override code that indicates the prescriber has been consulted.
   
   
3. Buprenorphine for medication-assisted treatment will not trigger the edit.
   
   
4. Hard edit at 200 morphine milligram equivalents
   
   
1. Beginning Jan. 1, 2017, CMS required sponsors to implement a cumulative opioid edit.
   
   
2. The edit will trigger when a member’s cumulative MME per day across their opioid prescriptions reaches or exceeds 200 MME.
   
   
3. Claims that trigger the edit will be stopped at the point of sale and require prior authorization for processing.
   
   
5. Hard edit seven-day supply limit for initial opioid fills
   
   
1. Hard edit to limit initial opioid prescription fills for the treatment of acute pain to no more than a seven-day supply for opioid naïve members, who are members who haven’t filled an opioid prescription in the preceding 108 days.
   
   
2. This includes short- and long-acting opioids, except buprenorphine for medication-assisted treatment, which won’t trigger the edit.
   
   
6. CARA Drug Management Program
   
   
1. CMS requires sponsors to establish drug management programs for members who are at-risk of overuse and allow sponsors to limit members’ coverage for frequently abused drugs to certain prescribers and pharmacies. This is known as a lock-in.
   
   
2. A member specific point of sale claim edit may be implemented after case management with the prescribers and notice to the beneficiary.
   
   
3. The member will have to meet clinical guidelines based on the level of opioids they are taking and the fact that they are obtaining them from multiple pharmacies and prescribers to be eligible.
   
   
7. Monitoring for concurrent opioid and opioid-potentiator use
   
   
1. CMS has requested increased vigilance and monitoring of members taking the combination of opioids and opioid-potentiator medications (gabapentin, pregabalin).

Providers can find out more about Part D coverage at the CMS website.** This website also includes educational materials about Medicare prescription coverage for doctors and other health care professionals.

** Blue Cross Blue Shield of Michigan doesn’t own or control this website.