To assist Medicare Part D sponsors with monitoring efforts and potentially avoid overutilization of opioids in the elderly Medicare population, CMS has deployed numerous strategies over the past several years to identify and deter opioid abuse. In the past, these efforts included monitoring Prescription Drug Events (PDEs) for opioid usage and screening them against Morphine Milligram Equivalency (MME) standards to alert sponsors to potential overuse situations. In recent years, CMS has also instructed sponsors to implement pharmacy point of sale (POS) edits to assist in the identification of opioid overutilization proactively. Per the 2019 Call Letter, CMS continues to further enhance additional editing at POS to reduce the potential for opioid addiction with new edits for sponsors and PBMs to implement.
To balance reducing the harm posed by opioids with an individual’s need for access to appropriate pain relief, CMS has issued guidance for Medicare Part D members that have not utilized opioids in the past. CMS expects all Part D sponsors to implement a hard safety edit to limit initial opioid prescription fills for the treatment of acute pain to no more than a 7 days supply. CMS recommends a look-back period of at least 60 days and should include both short-acting and long-acting opioids (excluding buprenorphine). Since this is viewed as a safety edit, it can be applied during transition. Currently there is no MME edit for opioid naïve patients but sponsors must have a way to override this edit due to exclusions.
Next, all Medicare Part D sponsors are expected to implement a real-time, POS opioid care coordination edit at 90 MME per day. Sponsors should instruct the pharmacist to consult with the prescriber, document the discussion, and if the prescriber confirms intent, use an override code that specifically states that the prescriber has been consulted. Sponsors have the flexibility to include a prescriber and/or pharmacy count in the opioid care coordination edit. As with the opioid naïve edit, sponsors must have a way to override this edit due to exclusions as well as system logic developed to prevent the edit from triggering after the initial override via pharmacy or coverage determination. Sponsors will continue to have the flexibility to use a hard edit at or above 200 MME in conjunction with the 90 MME care coordination edit if they deem it to be clinically appropriate.
CMS also expects Medicare Part D plan sponsors to implement a soft POS edit for duplicative long acting opioid therapy, with or without a multiple prescriber criterion. CMS stressed that it is important that a sponsor should only implement this edit if it has the technical ability to not reject buprenorphine claims being used as part of medication assisted treatment (MAT).
Lastly, CMS expects Medicare Part D sponsors to implement additional soft safety edits at POS to alert the pharmacist about duplicative opioid therapy and concurrent use of opioids and benzodiazepines. Sponsors may include criteria for multiple prescribers, dose and / or days’ supply.
CMS recognizes that multiple opioid POS edits could potentially generate a combination of messages and soft or hard rejects that may cause confusion to the pharmacy and member.
It is recommended that contracts create a hierarchy for the opioid POS edit messaging to reduce confusion. Lastly, the following members should be excluded from these interventions: residents of a long-term care facility, hospice care, receiving palliative or end-of-life care, treatment of active cancer-related pain and beneficiaries with a medication-assisted treatment (MAT), such as buprenorphine.
