Medication Safety and Monitoring
Medicare Opioid Medication Coverage
What are opioids?
Opioids are a class of drugs that include pain relievers, such as hydrocodone, oxycodone, and morphine. This class also includes the synthetic opioid fentanyl and the illegal drug heroin. Prescription opioids are for pain treatment for certain health conditions or after surgery or a serious injury. Although opioids can be an important part of a treatment plan, there are risks associated with them. Opioid drugs are addictive. As many as one in four people who have long-term opioid prescriptions struggle with addiction. Addiction can cause symptoms of uncontrollable cravings, inability to control drug use, compulsive drug use, inability to meet obligations of daily life, and use despite doing harm to oneself or others. If you are concerned about your medication use, please contact your doctor. For additional help or information, call the national SAMHSA helpline toll-free at 800-662-4357 or TTY 800-487-4889, or visit the Substance Abuse and Mental Health Services (SAMHSA) website at
FindTreatment.samhsa.gov.
What has changed?
The Centers for Medicare and Medicaid Services (CMS) and PacificSource Medicare are teaming up to offer ways to reduce wasted opioids, decrease your costs, and address the risk of opioid misuse. To combat this risk, CMS is requiring all Medicare Advantage health plans to implement certain limits on new prescriptions for opioids.
Who will this impact?
Medicare members who receive a new prescription for an opioid will be limited to an initial 7-day supply for those who do not have a history or opioid use.
What are the safety alerts at the pharmacy from Medicare Health plans?
PacificSource Medicare cares about your health. When electronic claims for certain high risk medication such as high doses of opioids are submitted, PacificSource Medicare will send a safety alert to your pharmacy to make sure the medication will not harm you. Some of these safety alerts will require your pharmacist or PacificSource Medicare to review your prescription with your doctor to make sure the medication is safe. If your prescription cannot be filled as written, including the full amount on the prescription, you or your doctor can contact PacificSource Medicare for a coverage determination. For more information, please see Safety and Monitoring Program for High-Risk Medication Use.
How will this reduce waste, cost, and misuse?
By limiting new opioid prescriptions to a 7-day initial supply, you won’t be left with unused opioids and you only pay for what you need. By not having extra medication lying around, you are helping fight opioid misuse, which can happen even in your own home with children, grandchildren, friends, or yourself.
What if I need more than a 7-day supply?
The Center for Disease Control and Prevention (CDC) has noted that most acute injuries require less than 3 days of opioids for pain and only in rare cases require more than 7 days of opioids. If you are still in pain after 7 days, your provider can write a new prescription.
What do I need to do?
If you have a scheduled procedure or surgery, please discuss these changes with your doctor in case they affect your care.
Have questions or need help?
Rest assured that PacificSource Medicare is committed to helping you get the healthcare coverage you need. If you are impacted by any of these changes, we will work with you or your doctor to discuss any needed steps.
Safety and Monitoring Program for High-Risk Medication Use
Based on rules from the Centers for Medicare and Medicaid Services (CMS), PacificSource Medicare is implementing chronic opioid use coordination changes for opioid utilization to prevent abuse and misuse of frequently abused drugs. These new guidelines will become part of the PacificSource Medicare drug management program, broadening the outreach and education throughout service areas. The goal is to reduce the risk of opioid overdose and help members with a potential opioid-use disorder receive treatment.
How is abuse and misuse identified?
A review the prescription-fill history for any of the following at-risk behaviors:
- A high number of controlled substance claims (hydrocodone, oxycodone, tramadol)
- Multiple prescribers of controlled-substances prescriptions filled at multiple pharmacies
- Cumulative opioid doses at or above 90 milligrams of morphine equivalents
- Combinations of opioid potentiators, such as gabapentinoids and benzodiazepines
How will this affect me?
If identified at your pharmacy:
- The pharmacist will receive an alert that there is a safety concern and to contact the prescribing provider for verification.
- The dispensing pharmacist will use his or her clinical judgment before inputting override codes required before the opioid claim can pay.
When identified by PacificSource Medicare:
- Clinicians will review identified claims for risk assessment.
- If a risk of medication abuse or misuse is identified, the health plan sends letters to you and your doctor, addressing the individual situation.
- Members continuing to use high-risk medications may be limited to a single doctor and pharmacy. We will work with that doctor to identify the best options for the member.
If you have any of the following conditions or are filling buprenorphine products as part of a medication-assisted treatment plan, you will be excluded from this program.
- On Hospice, palliative, or end-of-life care
- Active treatment for cancer pain
- Resident in a long-term care facility