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Opioid AwarenessPharmacy

Our policy on opioid management  

June 9, 2017    

Every year, the Centers for Disease Control and Prevention (CDC) analyze and highlight the states with the highest rates of overdose-related deaths. States with significant increases in deaths due to drug overdoses were mainly in the Northeast and South Census Regions.1,2 In response, many federal and state agencies have released guidelines to address this growing opioid epidemic, and Independence has updated our opioid management strategy.

Recommendations from federal and state-level opioid guidelines3,4

In 2013, the Centers for Medicare & Medicaid Services (CMS) initiated the Overutilization Monitoring System (OMS) to monitor patients with the following criteria:

  • use more than 120 MED* for at least 90 consecutive days;
  • see more than three prescribers;
  • go to more than three pharmacies.

As a result of the OMS’s interventions, CMS reported a 47 percent decrease in Part D beneficiaries overutilizing opioids (based on the above criteria) from 2011 to 2015. Since the initiation of OMS, CMS has recommended a threshold limit of 120 MED. The OMS showed that the threshold limit of 120 MED was a sensitive marker to assess the risk of opioid-related death and identify overutilizers.

Other federal and state-level agencies have followed the CMS recommendation and created their own threshold limits. The CDC supported using a threshold limit of 90 MME* for all opioid users in its 2016 guidelines. Based on a systematic review of different trials, the CDC found evidence that discouraged prescribing 90 MME or more.

Updates to Independence’s opioid management strategy

As a key stakeholder in the opioid epidemic, Independence has enhanced our opioid management strategy for 2017. Below is an outline of some of the updates that will apply to our commercial and consumer business (non-Medicare), which include the utilization management that will be used by Independence in an effort to encourage appropriate prescribing of opioids. According to CDC researchers, the probability that an opioid-naive patient would become a chronic opioid user increased sharply after as little as five days of use.5 The updated management strategy uses the 90 MME* threshold identified by the CDC in an effort to encourage appropriate use of prescription opioids for acute or chronic pain.

Opioid management for acute pain

  • Prior authorization is required for the following:
    • – all opioid products whose standard dosing exceeds 90 MED*;
    • – all opioid patches (as of July 1, 2017);
    • – most strengths of long-acting opioids.
  • Effective July 1, 2017, Independence will implement a cumulative five-day supply per 30-day period for members newly initiated on an opioid (i.e., have not received an opioid within the last 30 days). If additional days’ supply is required, a prior authorization will be needed. This applies to:
    • – all opioid products whose standard dosing is ≤ 90 MED* (e.g., ≤ 10 mg oxycodone IR);
    • – all opioid-containing cough and cold products;
    • – all butalbital products.

Opioid management for chronic pain

  • A Patient-Provider Agreement is required. You can view samples of a Patient-Provider Agreement online.
  • Prior authorization is required annually.

Medication Assisted Treatment (MAT) for opioid addiction

  • As of May 1, 2017, prior authorization was removed from all buprenorphine/naloxone products (i.e., Zubsolv®, Bunavail®).
  • Effective July 1, 2017, buprenorphine products are available without prior authorization for a cumulative 180-day supply per rolling 365 days. A prior authorization must be requested if additional days’ supply is needed within one year.
  • Prior authorization is required when an opioid is filled within two months of a paid claim of a buprenorphine-containing MAT (e.g., Bunavail®, Suboxone®, Zubsolv®, Subutex®).

For additional information on Substance Use Treatment Programs, members can refer to the mental health/substance abuse telephone number on the back of their ID card.

*The following acronyms are used to define the total daily dose of opioid converted to morphine equivalents: MED: Daily morphine equivalent dose in milligrams; MME: Morphine milligram equivalents per day; OME: Oral morphine equivalents per day.

1Rudd RA, Seth P, David F, Scholl L. “Increases in drug and opioid-involved overdose deaths-United States, 2010-2015.” Centers for Disease Control and Prevention Morb Mortal Wkly Rep. Accessed March 21, 2017. Available from: www.cdc.gov/mmwr/volumes/65/wr/mm655051e1.htm.

2Centers for Disease Control and Prevention/National Center for Health Statistics. ”Drug overdose death data.” 2013 [updated 2016 Dec 16; cited 2017 Apr 21]. Available from: www.cdc.gov/drugoverdose/data/statedeaths.html.

3Centers for Medicare & Medicaid Services. “Analysis of proposed opioid overutilization criteria modifications in Medicare Part D.” 2017. Available from: www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/Downloads/Proposed-Opioid-Overutilization-Criteria-Modifications-v-02012017.pdf.

4Dowell D, Hagerick TM, Chou R. “CDC guideline for prescribing opioids for chronic pain—United States, 2016.” JAMA. 2016;315(15):1624-45. Available from: http://jamanetwork.com/journals/jama/fullarticle/2503508.

5Walker, Molly. “Longer Initial Opioid Prescription Ups Risk of Chronic Use.” MedPage Today. March 26, 2017. Available from: www.medpagetoday.com/PainManagement/PainManagement/63888?xid=nl_mpt_DHE_2017-03-17&eun=g807263d0r&pos=2.





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