Medicare Part D Opioid Policies from CMS effective Jan. 1, 2019

The Centers for Medicare and Medicaid Services (CMS) finalized new opioid policies for Medicare drug plans starting on Jan. 1, 2019

What providers need to know

Part D plans are expected to implement safety alerts (pharmacy claim edits) for pharmacists to review at the time of dispensing the medication to prevent the unsafe utilization of drugs.

The new policies include improved safety edits when opioid prescriptions are dispensed at the pharmacy, and drug management programs for patients determined to be at-risk for misuse or abuse of opioids or other frequently abused drugs. Here are the major changes, although Priority Health has already implemented some of these on our own (and see the table below for more details):

  • New starts for an opioid are limited to a 7 day supply
  • When cumulative Morphine Milligram Equivalent exceed 90mg per day, care coordination may be triggered
  • Pharmacy alerts for when an opioid and benzodiazepine are taken concurrently
  • Hard edit when Morphine Milligram Equivalent dosage exceeds 200mg per day (Priority Health has already been doing this)

What providers need to do

CMS encourages prescribing providers to respond to pharmacists' outreach in a timely manner and give the appropriate training to on-call prescribers when necessary to resolve opioid safety edits expeditiously and avoid disruption of therapy.

Questions? See the CMS policy page.