Early last year, the Centers for Medicare & Medicaid Services (CMS) published a roadmap outlining our efforts to address the national opioid epidemic.  The roadmap details our three-pronged approach, including prevention of new cases of opioid use disorder (OUD), expanding access to treatment for patients who have already developed OUD, and using data from across the country to better target our prevention and treatment activities.

While illicit opioid use is part of the epidemic, prescription opioids provided by physicians can also contribute to the crisis when not used carefully. As Medicare pays for a significant amount of prescription opioids, we strive to ensure appropriate stewardship of these medications that can provide a medical benefit but also carry a risk for our beneficiaries.

As part of our prevention efforts, we’ve introduced new Medicare Part D opioid safety policies to reduce prescription opioid misuse while preserving medically necessary access to these medications. 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. Medicare drug plans will perform additional safety checks by sending pharmacies an alert to review certain opioid prescriptions before they are filled. Safety alerts may cover situations like:

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. Part D beneficiaries may be limited to a 7-day supply or less for acute pain if they haven’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. 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 can’t be filled as written, including the full amount on the prescription, the pharmacist will give the beneficiary a notice explaining how they or their doctor can contact the plan to ask for a “coverage determination” (a decision about whether or not the plan will cover the drug).  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.

It’s important to note that these new policies are not “one size fits all,” and are deliberately tailored to address distinct populations of Medicare Part D prescription opioid users. These interventions do not apply to residents of long-term care facilities, beneficiaries in hospice, palliative, or end-of-life care, and beneficiaries being treated for active cancer-related pain.

The new policies also permit Part D plans to put drug management programs in place to help beneficiaries use opioids and other frequently abused medications safely. 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. The plan will send the beneficiary a letter if it will limit their access to these medications under its drug management program.  If so, the beneficiary and their doctor will have the right to appeal.

The new Medicare Part D opioid 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 continues to be committed to addressing the opioid crisis and helping our beneficiaries use prescription opioid pain medications more safely.

For more information on the new Part D opioid safety policies, visit https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE18016.pdf. 

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