What Prescribers Should Know about New Opioid Policies for Medicare’s Prescription Drug Program

Last Updated: Jan 25, 2019

stethoscope-prescription-pad-pillsNew opioid policies for Medicare’s Prescription Drug Program – known as Medicare Part D – took effect on Jan. 1, 2019. The Centers for Medicare and Medicaid Services (CMS) has implemented new safety alerts for pharmacists to review when dispensing medication.

The four new Medicare Part D opioid safety alerts are as follows:

  1. Seven-day supply limit for opioid naïve patients – Medicare Part D patients who have not filled an opioid prescription recently (such as within the past 60 days) will be limited to a supply of seven days or less. If a prescriber assesses upon re-evaluation that a patient will need additional opioid therapy, subsequent prescriptions will not be subject to the 7-day supply limit.
  2. Opioid care coordination alert at 90 morphine milligram equivalent (MME) – This policy affects Medicare patients who present an opioid prescription at the pharmacy and their cumulative MME per day across all their opioid prescriptions reaches or exceeds 90 MME. Some plans may only use this alert, which CMS says is not a prescribing limit, when the patient uses multiple opioid prescribers and/or dispensing pharmacies. Once a pharmacist consults with a prescriber on a patient’s prescription for a plan year, the prescriber will not be contacted on every opioid prescription written for the same patient after that, unless the plan implements further restrictions.
  3. Concurrent opioid and benzodiazepine use or duplicative long-acting opioid therapy – This alert is triggered when a patient is taking opioids and benzodiazepines at the same time or if the patient is on multiple duplicate long-acting opioids. The pharmacist will conduct additional safety reviews and the prescriber may be contacted.
  4. Optional safety alert at 200 MME or more – Certain plans may implement a hard safety alert when a patient’s cumulative opioid daily dosage reaches 200 MME or more. CMS says that some Part D plans use this alert only when the patient uses multiple opioid prescribers and/or opioid dispensing pharmacies. This safety alert is not a prescribing limit.

For each of these safety alerts, the physician or other prescriber has the right to request, on the patient’s behalf, a coverage determination for a drug or drugs, including the right to request an expedited or standard coverage determination in advance of prescribing an opioid.

Prescribers should be aware that these policies do not apply to residents of long-term care facilities, those in hospice care, patients receiving palliative or end-of-life care, and patients being treated for cancer-related pain. CMS says that, for cases in which a plan may not be aware that a patient is exempt due to one of these exclusions, a prescriber may wish to proactively initiate a coverage determination in advance of prescribing an opioid.

The new policies also include drug management programs (DMPs) for patients determined to be at risk for misuse or abuse of opioids or other frequently abused drugs.

For more details on the Part D opioid policies, including both safety alerts and DMPs, you can access CMS’ Information for Prescribers here. You can also find more information on CMS' Part D Drug Utilization Review webpage

Additional Resources

The Pennsylvania Medical Society has developed a variety of resources and education to help Pennsylvania physicians navigate the opioid abuse crisis. You can find these resources online at www.pamedsoc.org/OpioidResources

Pennsylvania Medical Society (PAMED) members with questions can contact our Knowledge Center at 855-PAMED4U (855-726-3348) or KnowledgeCenter@pamedsoc.org.

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