Pharmacy changes and claims system edits in response to opioid crisis
Effective Aug. 1, 2019, the Mississippi Division of Medicaid (DOM) will implement a new opioid initiative, which will affect pharmacy point-of-sale claims and will apply to beneficiaries enrolled in fee-for-service (FFS) Medicaid and all three MississippiCAN coordinated care plans. The initiative involves four changes that will directly impact Medicaid pharmacy/prescribing providers.
DOM has carefully developed the initiative over several years in response to the Drug Utilization Review (DUR) Board’s recommendations which align with the Centers for Disease Control and Prevention (CDC) Guideline for Prescribing Opioids for Chronic Pain, published in March 2016, the Mississippi State Board of Medical Licensure prescribing regulations, Gov. Bryant’s Opioid and Heroin Study Task Force recommendations, and following the Centers for Medicare and Medicaid Services (CMS) requirements .
DOM’s intent is to improve the safety and effectiveness of pain treatment and reduce the risks of long-term opioid therapy by taking a two-pronged approach:
- Steer opiate-naïve patients (new starts) toward the appropriate treatment of pain in an attempt to prevent them from becoming addicted to opioids.
- Allow patients currently being treated for chronic pain to remain on their medications with the understanding that denying their claims could lead to adverse unintended consequences.
The four (4) opioid-related changes to be implemented on Aug. 1, 2019 are:
- New opioid prescriptions for opiate-naïve patients must be for short-acting (SA) opioid.*
- SA opioid prescriptions for opiate-naïve patients can be filled for a maximum of two 7-day supplies in a 30-day period.*
- Opioid doses of Morphine Milligram Equivalents (MME) ≥ 90 will require prior authorization (PA).*
Any prescriptions (whether individual and/or cumulative daily sum of all opioid prescriptions for the patient) with a MME ≥ 90 will require PA with documentation that the benefits outweigh the risks and that the patient has been counseled about the risks of overdose and death.*
* Patients with a diagnosis of cancer or sickle-cell disease are exempt from the three edits above. The patient’s diagnosis code should be entered on the prescription to ensure that prescriptions process.
- Concomitant use of opioids and benzodiazepines will require PA. Clinical Exceptions:
Scenario 1 – Patient who is a chronic user of an opioid with new prescription for a benzodiazepine. For beneficiaries enrolled in FFS and Magnolia Health:
To allow for the short-term treatment of pre-procedure anxiety or other short-term anxiety, a prescription for up to 2 units of a solid oral dosage form of a benzodiazepine can be overridden at the point-of-sale by the dispensing pharmacist based upon his/her clinical judgment and consultation with the prescriber. A maximum of up to two 2-unit/2-day supply prescriptions (total of 4 units) may be overridden in a 60-day period.When the claim for the benzodiazepine denies, POS will send back an NCPDP Reject Code of 88 and the prospective (Pro) DUR segment. If the decision to fill 2 units has been reached, the pharmacist should then resubmit the claim, for up to 2 units, with a Professional Service Code (440-E5) of M0 (Prescriber consulted), a Result of Service code (441-E6) of 1G (Dispensed, with Prescriber Approval) and a Reason for service code (439-E4) of AT (Additive Toxicity).For beneficiaries enrolled in Molina Healthcare and UnitedHealthcare Community Plan:
Call the coordinated care organization (CCO)/pharmacy benefit manager (PBM) Help Desk
Scenario 2 – Patient who is a chronic user of a benzodiazepine with a new prescription for an opioid
For beneficiaries enrolled in FFS, Magnolia Health and Molina Healthcare:
To allow for the treatment of acute pain, the pharmacist will be allowed to dispense an SA opioid for a quantity sufficient for < a 3-day supply, according to the SIG, not to exceed 90 MME/day. Follow the same Pro DUR billing instructions in Scenario 1, above, and submit a day supply of < 3 days of the SA opioid.
PA will be required for long-acting (LA) opioid claims.
For beneficiaries enrolled in UnitedHealthcare Community Plan:
Call the CCO/PBM Help Desk
At this time, chronic users of SA opioids, LA opioids, benzodiazepines, or any combination thereof, will only be impacted by these four changes if their total daily dose of opioids is > 90 MME which will require prior authorization (PA).
In June and July, DOM proactively mailed letters to all prescribers with identified patients as taking opioids > 90 MMEs and instructed them to submit a PA request for that dosage.
DOM’s long-standing opioid monthly quantity limits will remain in effect.
Frequently Asked Questions will be posted on the DOM Pharmacy webpage.
For more information contact DOM’s Office of Pharmacy at 601-359-5253, Option 4.