New Policy Burdens Doc Prescribing Opioids Under Part D

Physicians may have to work harder and fight the federal bureaucracy to write new prescriptions for opioids covered under Medicare Part D under policies issued by the Centers for Medicare and Medicaid Services (CMS) on March 28.

“The new opioid policies include improved safety alerts at the pharmacy for Part D beneficiaries who are filling their initial opioid prescription or who are receiving high doses of prescription opioids,” CMS Principal Deputy Administrator for Operations Kim Brandt said in an online announcement.

Under the new policies, Medicare drug plans will be required to perform additional safety checks by sending alerts to pharmacies to review some opioid prescriptions before they are filled in such situations such as (but not limited to):

• “Possible unsafe amounts of opioids. The pharmacist or Medicare drug plan may need to perform a closer safety review of the prescription with the prescribing doctor if a Part D beneficiary receives opioid prescription(s) that exceed a certain amount.”
• First prescription fills for opioids for Part D beneficiaries might be limited to a 7-day or shorter supply for acute pain the patient hasn’t recently taken opioids (such as within the past 60 days). “The limit is based on medical best practices that show that the risk of developing an opioid use disorder increases after 7 days of use,” the announcement said, adding, “This policy is not intended for current users of prescription opioids.”
• “Use of opioids and benzodiazepines at the same time. These medications can be dangerous when taken in combination.”

If the prescription is kicked back, the pharmacy will tell the patient how she/he or the physician can contact the Part D plan for a coverage determination. “The beneficiary or their doctor may also ask the Part D plan for an exception to its rules before the beneficiary goes to the pharmacy, so they know in advance whether the prescription is covered,” the announcement said.

CMS is also implementing what it calls an “opioid care coordination alert.”

“This policy will affect Medicare patients when they present an opioid prescription at the pharmacy and their cumulative morphine milligram equivalent (MME) per day across all of their opioid prescription(s) reaches or exceeds 90 MME. Regardless of whether individual prescription(s) are written below the threshold, the alert will be triggered by the fill of the prescription that reaches the cumulative threshold of 90 MME or greater. It is the prescriber who writes the prescription that triggers the alert who will be contacted by the pharmacy even if that prescription itself is below the 90 MME threshold,” CMS said.

Brandt’s announcement said the new policies “are not ‘one size fits all,’ and are deliberately tailored to address distinct populations of Medicare Part D prescription opioid users.”

The new policies also give Part D plans the authority to have their own “drug management programs” under which, “If a beneficiary gets opioids from multiple doctors or pharmacies, the beneficiary may need to receive their medications from specific doctors or pharmacies to ensure appropriate care coordination.”

If a beneficiary’s access is limited or denied, the beneficiary or physician can appeal to the Part D insurer.

The new policies “encourage collaboration and care coordination among Medicare drug plans, pharmacies, prescribers, and patients, in order to improve opioid management, prevent opioid misuse, and promote safer prescribing practices,” CMS said.

More details can be found at: “A Prescriber’s Guide to the New Medicare Part D Opioid Overutilization Policies for 2019.”