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Using opioid pain medications safely
The Centers for Medicare & Medicaid Services (CMS) and Elevate Medicare Advantage want to make sure our Medicare members are using opioid pain medications safely. Opioid medications (also known as “narcotics”) are used to ease pain. Some types are fentanyl, morphine, oxycodone and tramadol. These medications can be dangerous when taken at high doses and/or with other drugs, such as benzodiazepines. Benzodiazepines are medications commonly used for anxiety and sleep. Some types are diazepam, lorazepam and temazepam.
To make sure our members are taking these medications safely, Elevate Medicare Advantage 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 Elevate Medicare Advantage members taking opioid medications.
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 request a coverage determination, 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.
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.
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.
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. To get more than a seven-day supply filled, a coverage determination will be needed.
For members taking two different types of long-acting opioid medications (e.g. 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.
The criteria used to identify members for this program are based on either of the following:
- Members utilizing an average daily morphine milligram equivalent (MME) equal to or exceeding 90 mg within the past 6 months AND either:
- Have received opioids from 3 or more prescribers and 3 or more pharmacies,
OR - Have received opioids from 5 or more prescribers regardless of the number of dispensing pharmacies
- Have received opioids from 3 or more prescribers and 3 or more pharmacies,
- A medical claim with a primary diagnosis of opioid-related overdose within the last 12 months AND a Part D opioid prescription drug claim (excluding medication assisted treatment) within the last 6 months
If a member is being reviewed for the DMP, they will get a notification letter about the DMP and their provider will be contacted. If a member is determined to be at risk of opioid misuse, the plan may limit opioid medications to only one prescriber and/or only one pharmacy.