In recent years, the Centers for Medicare and Medicaid Services (CMS) has taken a multifaceted approach to addressing the nation’s mounting issue of misuse and abuse of opioids. As part of this effort, CMS works closely with Part D plans to improve drug utilization controls and better manage overutilization of opioids. The goal is to increase medication safety, while maintaining access to needed medications. Harvard Pilgrim supports this goal and is taking steps to address it in our Medicare Advantage plans — as well as extending these efforts to our commercial products. Effective January 1, 2017, Harvard Pilgrim is introducing additional safety and quantity edits for opioids, at the point of sale, to our Medicare Advantage and commercial plans.
Medicare Opioid Cumulative Dosing Program
Harvard Pilgrim’s Medicare Opioid Cumulative Dosing Program is an edit that will focus on members of our Medicare Advantage plans filling prescriptions for non-injectable opioids, as well as covered cough and cold products containing opioids. This edit includes a prescriber count and a set of morphine equivalent dose (MED) thresholds. If a Medicare Advantage member has filled or is filling prescriptions for opioids written by three or more prescribers and the MED is greater than or equal to 120mg, a maximum dose alert with a soft stop will be placed on the dispensing of the requested medication. A soft stop can be overridden at the pharmacy level at the clinical discretion of the dispensing pharmacist.
However, if a Medicare Advantage member has filled or is filling prescriptions for opioids written by three or more prescribers and the MED is greater than or equal to 200mg, a maximum dose alert with a hard stop will be placed on the prescription. In order for a hard stop to be overridden, a coverage determination will be required. Additionally, the edit will include logic to minimize false positives by accounting for exceptions, such as hospice care, claims for cancer drugs, and reasonable overlapping dispensing dates for refills of existing medication therapy.
Upon running into a hard or soft edit, the provider or patient may request a coverage determination by filling out our Medicare Prescription Drug Determination Request Form and sending it by fax to 888-807-6643, or by mail to:
MedImpact Healthcare Systems, Inc.
Attn: Prior Authorization Department
10181 Scripps Gateway Court
San Diego, CA 92131
Commercial Opioid Cumulative Dosing Program
Harvard Pilgrim will also be implementing a soft stop edit for members of our commercial plans; if a member of a Harvard Pilgrim commercial plan has filled or is filling prescriptions for opioids written by three or more prescribers and the MED is greater than or equal to 120mg, a maximum dose alert with a soft stop will be placed on the dispensing of the requested medication. A soft stop can be overridden at the pharmacy level by the dispensing pharmacist.
Useful Resources for Opioid Prescribing
Harvard Pilgrim recently created a new page in the Pharmacy section of our Provider website called “Useful Resources for Opioid Prescribing.” Here you can find links offering valuable information on topics like opioid prescribing, opioid risk evaluation, safe storage and disposal of opioids, prescriber and patient education, and overdose prevention. You’ll also find a MED calculator, an online tool to calculate the morphine equivalent dose of all opioids.
If you have any questions regarding pharmacy issues, including opioid prescribing, feel free to call Pharmacy Services at 617-509-9060.