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Network Matters
News and Information for the
Harvard Pilgrim Health Care Network

January 2019

New Opioid Safety Edits for 2019 Medicare Advantage Plans


In response to the current nationwide opioid epidemic, the Centers for Medicare and Medicaid Services (CMS) announced new mandatory strategies in 2019 to further support preventing and combating prescription opioid overuse through improved concurrent drug utilization review.

CMS has tailored its approach to help the distinct populations of Medicare Part D opioid users, including new opioid users (opioid naïve), chronic opioid users, and those with potentially problematic concurrent medication use. In alignment with CMS’s efforts, Harvard Pilgrim is implementing the following formulary-level opioid safety edits for 2019 for our Medicare Advantage plans. Please note that members in hospice care, at a long-term care (LTC) facility or with a history of cancer therapies filled at a pharmacy are exempt from these edits.

Opioid Care Coordination Safety Edit

If a member fills a prescription for opioids and the morphine milligram equivalent (MME) is greater than or equal to 90MME, a maximum dose alert with a soft stop will be placed on the dispensing of the requested medication (for 2018 this limit was 120MME). This can be overridden at the point of service by the pharmacist with an override code indicating that the prescriber has been consulted and confirmed the intent.

Opioid Naïve 7-Day Supply Limitation

This edit limits the prescription of short-acting or long-acting opioids to seven days if the patient has no history of opioid prescriptions in the previous 60 days (and is thus considered “opioid naïve”). If a provider writes a prescription for an opioid to an opioid naïve patient for more than seven days, the pharmacy can only dispense seven days’ worth and will void the remainder of the prescription.

Opioid – Benzodiazepine Concurrent Use Edit

If a member fills prescriptions for an opioid and benzodiazepine written by two or more prescribers, a soft edit will stop the claim. This can be overridden at the point of service by the pharmacist with an override code indicating that the prescriber has been consulted and confirmed the intent.

Duplicative Long-Acting Opioid Edit

If a member fills prescriptions for two or more long-acting opioids written by two or more prescribers, a soft edit will stop the claim. This can be overridden at the point of service by the pharmacist with an override code indicating that the prescriber has been consulted and confirmed the intent.

There are proactive steps you can take to minimize disruption for your patients, such as requesting coverage determinations in advance for chronic pain patients. Dispensing pharmacists may reach out to your office for consultation regarding members who encounter these edits at the point of service. It is imperative that these requests are addressed promptly. We appreciate your assistance in responding to outreach regarding opioid safety alerts in a timely manner and providing any necessary information.

As a reminder, you have the option to refer your patients for care management services by calling 1-866-750-2068 to work with a Harvard Pilgrim nurse care manager.

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