In addition to the opioid naïve 5 and 7-day limits, the Alabama Medicaid Agency is working toward implementing cumulative Morphine Milligram Equivalent (MME) edits in early 2019.
Higher doses of opioids are associated with a higher risk of overdose and death; even relatively low dosages (20-50 MME per day) may increase risk.1 Alabama has led the nation for the past six years in the opioid prescribing rate per 100 population (121 in 2016; 107.2 in 2017) and had nearly three times more opioid prescriptions per 100 population than New York.2
The Alabama Medicaid Agency previously executed many programs to address opioid use such as monthly maximum unit limits, therapeutic duplication edits, Drug Utilization Review (DUR) letters, academic detailing report cards and face to face visits, prior authorization, and other educational efforts. Most recently, Medicaid implemented limits for opioid naïve patients to limit first-time use to five days for children and seven days for adults, limiting daily use to 50 MME. Overrides are available for medical necessity.
In an effort to continue combating the opioid crisis, beginning May 1, 2019*, Alabama Medicaid will limit the amount of cumulative MMEs allowed per day on claims for opioid experienced recipients. The edit will begin at 250 cumulative MME per day and will gradually decrease over time. The final MME target is 90 MME per day.
Claims for opioids that exceed the maximum daily cumulative MME limit will be denied. Claims prescribed by oncologists will be excluded from the edit. Long term care and hospice patients will also be excluded; however, children will be included. Overrides for quantities exceeding the MME limit for medical necessity may be submitted to Health Information Designs (HID). Information regarding override requirements and MME examples will be made available on the Alabama Medicaid Agency website closer to the implementation of the new limitations.
The Agency will implement a robust educational program to include academic detailing visits to the prescribers and pharmacies of the first round of affected patients, extensive training, and notifications to the impacted providers through a provider ALERT closer to implementation. Please check the Alabama Medicaid Pharmacy webpage for additional information: http://www.medicaid.alabama.gov/content/4.0_Programs/4.3_Pharmacy-DME.aspx
*At the time of article submission, the implementation date is May 1, 2019, for a ‘phase in’ for 250MME/day. During the phase-in period, a universal prior authorization number will be provided on the pharmacy claim rejection, with an explanation to notify the affected patient/prescriber. Hard stops/edits will begin after the phase-in period.
- “Calculating Total Daily Dose of Opioids for Safer Dosage”. CDC. https://www.cdc.gov/drugoverdose/pdf/calculating_total_daily_dose-a.pdf. Accessed 2/1/2019.
- “Understanding the Epidemic”. Centers for Disease Control and Prevention. https://www.cdc.gov/drugoverdose/epidemic/index.html. Accessed 2/1/2019.