Who is impacted?

All Medicare members with prescription drug coverage who are prescribed a new prescription for opioids

All Medicare members with prescription drug coverage who are prescribed high risk medications of frequently abused drugs

Members who are hospice, end of life care, being treated for active cancer pain or residents of resident of a long-term care facility are excluded from the opioid overutilization strategies.

What drugs are included in the overutilization initiatives? This strategy is focused on identifying at risk members on frequently abused drugs. Drugs from the following therapeutic categories are included in the overutilization initiatives:

Opioids (e.g., opioids such as fentanyl, hydrocodone/APAP)

Benzodiazepines  (e.g., diazepam, triazolam)

Non-benzodiazepine sedatives /hypnotics (e.g., zolpidem, zaleplon)

Other drugs with abuse potential (e.g., cyclobenzaprine, gabapentin)

CNS Stimulants (e.g., methylphenidate, modafinil)

Other Controlled Substances (e.g., dronabinol, testosterone)

Buprenorphine drugs for medication-assisted treatment (MAT) are excluded

What are the Initiatives?

Opioid naïve patients will be limited to a 7 day supply of their first opioid prescription. The look back must be at least 60 days.  PacificSource will have a lookback of 90 days for opioid fill to determine if patient is opioid naive. New prescriptions greater than 7 day supply will require a prior authorization for coverage.

Health Plan sponsored case management may limit coverage of frequently abused drugs for at risk patients based on CMS guidelines

At risk patients may be identified based on drug regimen (examples: high opioid doses greater than 90 Cumulative daily MME, high risk drug combinations of frequently abused drugs)

At risk patients may also be identified based on utilization patterns (examples multiple prescribers, multiple pharmacies)

CMS revised the opioid overuse performance measures and added the new performance measure, for concurrent use of opioids and benzodiazepines.

There are detailed reporting requirements by Health plans to CMS for these initiatives.

Please contact PacificSource for additional questions.