The Center for Medicaid and Medicare Services (CMS) and Denver Health Medical Plan (DHMP) want to make sure our Medicare members are using opioid pain medicines safely. Opioid medicines or “narcotics” are used to ease pain. Types of these medicines include oxycodone, morphine, fentanyl and Vicodin. These medicines can be dangerous to your health when taken at high doses and/or with other drugs, such as benzodiazepines. Benzodiazepines are medicines such as diazepam, temazepam and lorazepam, used commonly for anxiety and sleep.
To make sure our members are taking these medicines safely, DHMP has Formulary-Level Opioid Point-of-Sale (POS) Safety Edits and a Drug Management Program in place to monitor and review members’ use of opioids. “POS” means that these edits take place at the pharmacy when you are filling a prescription. If you do not take any opioid pain medicines, or if you have a diagnosis of pain from cancer, sickle cell disease, are in hospice or long term care, or are receiving palliative care, this program does not apply to you. There are several different edits that may affect members taking opioid medicines for pain:
Opioid Care Coordination Safety Edit
If you reach certain opioid medication doses [90 Morphine Milligram Equivalent (MME) or 200 MME and higher] and if the medicines are prescribed by two or more providers, you may need a coverage determination before the plan will pay for your medicine.
Opioid and Benzodiazepine Concurrent Use Edit
If you are taking both benzodiazepines and opioids at the same time and they are prescribed by two or more providers, you may need a coverage determination before the plan will pay for your medicine.
Opioid Naïve Day Supply Limitation Edit
If you have not taken any opioid medicines in the last 60 days and go to fill an opioid prescription, you will only be able to get a seven day supply dispensed. In order to get more than a seven day supply filled, a coverage determination will be needed.
Long-Acting Duplicative Therapy Edit
If you are taking two different types of long-acting opioid medicines [i.e. Oxycontin and morphine sulfate extended release (ER)] at the same time and they are prescribed by two or more providers you may need a coverage determination before the plan will pay for your medicine.
Drug Management Program (DMP)
If you are getting opioid medicines from different providers and filling at different pharmacies, the plan may limit how you receive these medicines to only one prescriber and/or filled at only one pharmacy. You will get a letter if you are under review for the DMP and your provider will be contacted before a restriction is put in place.
Coverage determinations that ask for an exception to these edits will be handled within 24 hours from the time the plan receives the request to prevent any delays in care.
If you have questions about these edits you can talk to your provider, the pharmacy you fill your prescriptions at or call Health Plan Services. To start a prior authorization, call Health Plan Services at 303-602-2111 or 1-877-956-2111. TTY users should call 711. Our hours of operation are 8 a.m. - 8 p.m. seven days a week.