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 medications safely. Opioid medications (also known as “narcotics”) are used to ease pain. These types of medications include oxycodone, morphine, fentanyl and Vicodin. These medications can be dangerous when taken at high doses and/or with other drugs, such as benzodiazepines. Benzodiazepines are medications most commonly used for anxiety and sleep that include diazepam, temazepam and lorazepam.
To make sure our members are taking these medications safely, DHMP has Formulary-Level Opioid Point-of-Sale (POS) Safety Edits that take place at the pharmacy when members fill a prescription. Additionally, there is a Drug Management Program to review and monitor members’ use of opioids.
These edits and programs do not apply to members taking opioids for palliative care, a diagnosis of cancer pain, a diagnosis of sickle cell disease, or are enrolled in a hospice or long-term care facility. The following is a description of the different edits that may affect DHMP members taking opioid medications:
Opioid Care Coordination Safety Edit
For members that reach certain opioid medication doses [90 Morphine Milligram Equivalent (MME) or 200 MME and higher] and have opioid medications prescribed by two or more providers, a coverage determination may be needed before the plan will pay for the opioid medications.
Opioid and Benzodiazepine Concurrent Use Edit
For members taking both benzodiazepines and opioids prescribed by two or more providers at the same time, a coverage determination may be required before the plan will pay for these medications.
Opioid Naïve Day Supply Limitation Edit
For members that have not taken any opioid medications in the last 60 days and go to fill an opioid prescription, only a seven-day supply can be dispensed. In order to get more than a seven-day supply filled; a coverage determination will be needed.
Long-Acting Duplicative Therapy Edit
For members taking two different types of long-acting opioid medications [i.e. Oxycontin and morphine sulfate extended release (ER)] at the same time and they are prescribed by two or more providers, a coverage determination may be needed before the plan will pay for these medications.
Drug Management Program (DMP)
For members identified as getting medications from different providers and filling at different pharmacies, the plan may limit how the member can receive these medications. The plan may limit these medications to only one prescriber and/or only one pharmacy. If a member is being reviewed for the DMP, they will get a notification letter about the DMP and their provider will be contacted before a restriction is put in place.
Coverage determinations reviewed for 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.