Skip to content

News

January 16, 2018

Opioid Management Program – Effective April 1, 2018

BACKGROUND

The National Centers for Disease Control and Prevention (CDC) has classified prescription opioid drug abuse as a national epidemic. In 2010, South Carolina ranked 23rd nationally in overdose deaths. South Carolina has also been ranked by some sources as “worse than average” when considering the number of opioid prescriptions filled annually.

National sources support the conclusion that the more opioids prescribed in a given region, the more likely it was that there would be an associated increase in addiction and overdose deaths.

Opioid addiction has been declared a national public health emergency, with the president requesting immediate action from government and health care entities to combat the issue. In addition, 35 state attorneys general, including South Carolina’s, have signed a letter asking insurers to implement programs and benefit designs that cover non-opioid treatments and increase their accessibility as part of health coverage policies.

PROGRAM OVERVIEW

PAI is dedicated to doing its part to reduce the over-prescribing of opioids to ultimately help reduce the number of new opioid addicts. The Pharmacy & Therapeutics (P&T) Committee has worked diligently to develop an Opioid Management Program slated to begin April 1, 2018. The P&T Committee based its recommendations and decisions on the guidance set forth by CDC. The program will consist of daily quantity limits specific to each drug, along with prior authorization for certain prescribing situations.

A few highlights of the program include:

  • An initial days supply fill limit for all short acting/immediate release (IR) opioids.
  • Specific day supply initial fill limit for all long acting/extended release (ER) opioids, provided the patients’ prescription history has proof of a previous fill of an IR opioid prescription in the past 90 days.
  • All daily supply limits for IR and ER opioids are calculated based on 90 MME (morphine milligram equivalents) a day. Requests for quantities above 90 MME a day will require prior authorization.
  • If the request for quantities above 90 MME is approved, patients will be allowed to fill up to a max of 120 MME per day.
  • Prior authorization criteria will be implemented to manage the allowed appropriate daily limits and to encourage ongoing physician monitoring of patients on opioid therapy.

PROGRAM IMPACT

The Opioid Management Program will apply to all commercial plans. Groups do not have the option to opt out of the program. The program does not apply to ACA members and plans, as these members are subject to a similar program administered by CVS Caremark. CVS Caremark is a division of CVS/Health, an independent company that provides pharmacy services on behalf of PAI. Patients undergoing cancer treatment, palliative and end-of-life care will be exempt from the program requirements due to their conditions/diagnoses.

PROGRAM COMMUNICATIONS

Providers: We will send letters to all in-state providers detailing the program approximately 90 days before it starts.

Members: We will send letters to members impacted by the new quantity limits and/or prior authorization requirements approximately 60 days before the program starts.

PROGRAM DETAILS

IR For Acute/Chronic Pain

  • All IR opioid agents will have a seven-day supply (90 MME a day) initial fill limit in 30 days.
  • If a member has a seven-day or greater supply of an IR or ER opioid in his or her claims history in the past 90 days, the IR opioid will be covered for up to the initial quantity limit (90 daily MMEs for 30 days).
  • The member must be evaluated and monitored for the development of opioid use disorder, and the member’s pain will be reassessed after the initial prescription or a dose increase and every three months thereafter. Approval criteria will include the required use of a validated assessment tool, such as the Current Opioid Misuse Measure (COMM) after three months of use.
  • Requests for doses greater than 120 MME a day will be considered on appeal.
  • Physician/member denial letters will include the allowed MME limits to educate prescribers and members on allowable quantities.

IR Opioid COMBINATION Products for Acute/Chronic Pain (products containing acetaminophen, ibuprofen, aspirin, other non-opioid pain medication in combination with the narcotic opioid)

  • All IR opioid combo products will have a seven-day supply (90 MME a day) initial fill limit in 30 days.
  • If a member has a seven-day or greater supply of an IR or ER opioid combination in his or her claims history in the past 90 days, the IR opioid combo product will be covered for up to the initial quantity limit (= 90 daily MME and = 4 grams APAP or ASA and = 3,200 mg ibuprofen for 30 days).
  • The member must be evaluated and monitored for the development of opioid use disorder, and the member’s pain will be reassessed after the initial prescription or a dose increase and every three months.
  • PAI criteria may include requirement of COMM evaluation after three months of use (effective three to six months post-implementation).
  • Requests for doses greater than 120 MME a day will be considered on appeal.
  • Post-limit PA requests will automatically reject for the following drugs/doses:
  • All IR opioid combo products will have a seven-day supply (90 MME a day) initial fill limit in 30 days.

- Acetaminophen doses greater than four grams (4,000 mg) a day
- Aspirin doses greater than four grams (4,000 mg) a day
- Ibuprofen doses greater than 3,200 mg a day

    • Physician/member denial letters will include the allowed MME limits to educate prescribers and members on allowable quantities.

    ER Opioid Products for Chronic Pain 

    • All ER opioid agents will have a 30-day supply (90 MME a day) initial fill limit.
    • If a member DOES NOT have a seven-day supply of an IR opioid or a 30-day supply of an ER opioid within his or her claims history in the past 90 days, then a PA will be required.
    • The patient must be evaluated and monitored for the development of opioid use disorder, and the patient’s pain will be reassessed after the initial prescription or any dose increase and every three months.
    • PAI criteria may include requirement of COMM evaluation after three months of use (effective three to six months post-implementation).
    • If a larger dose is needed, post-limit PA will be required with approval of up to 120 daily MME for 12 months.
    • Requests for doses greater than 120 MME a day will be considered on appeal.
    • Physician/member denial letters will include the allowed MME a day limits to educate prescribers/members on allowable quantities. 

    OPIOID QUANTITY MANAGEMENT Drug List, effective 4-1-2018

    « Back to List of News