Short-Acting Opioid Naïve Limits — Effective Nov. 1
Effective Nov. 1, 2018, the Alabama Medicaid Agency will begin implementing limits on short-acting opiates for opioid naïve recipients. The Agency defines “opioid naïve” as a recipient with no opioid claim in the past 180 days.
Edit Details:
- A 7-day supply limit for adults age 19 and older
- A 5-day supply limit for children age 18 and younger
- A maximum of 50 morphine milligram equivalents (MME) per day allowed on a claim for an opioid naïve recipient
- Any claim for a short-acting opioid for an opioid naïve recipient exceeding the maximum days’ supply limit or MME limit will be denied.
- Claims prescribed by oncologists will bypass the edit.
- Long-term care and hospice recipients are excluded.
- Refills of remaining quantities and/or new prescriptions filled within 180 days of the initial opioid naive claim will require an override.
- Refills of remaining quantities of prescriptions that are partially-filled will be allowed per State and federal law* but will require an override through Medicaid. See below for more details from the State Board of Pharmacy.
- For adults, the refill of the quantity remaining on the partial fill will not count towards the prescription limit if filled within 30 days of the original prescription. Monthly maximum unit quantities still apply.
- Overrides for quantities exceeding the maximum days’ supply limit or MME limit may be submitted to Health Information Designs (HID). Please see the Pharmacy Override External Criteria Booklet for information about override requirements. Please refer to the following link for more information regarding overrides for opioid naïve patients: http://www.medicaid.alabama.gov/content/4.0_Programs/4.3_Pharmacy-DME.aspx.
- A Recipient Information Sheet for prescribers and pharmacists to provide to recipients can be found at http://www.medicaid.alabama.gov/content/4.0_Programs/4.3_Pharmacy-DME.aspx.
IMPORTANT: A recipient may not pay cash for the remaining amount over 7 days for the same prescription of a Medicaid-paid opioid claim (ie a single fill/dispense/claim may not be ‘split billed’ to both Medicaid and cash). If the prescription to be paid by Medicaid exceeds the drug’s limit allowed, an override may be requested. Only if the override is denied, then the excess quantity above the maximum unit limit is deemed a non-covered service, and the recipient can be charged as a cash recipient for that amount in excess of the limit. A prescriber must not write separate prescriptions, one to be paid by Medicaid and one to be paid as cash, to circumvent the override process. FAILURE TO ABIDE BY MEDICAID POLICY MAY RESULT IN RECOUPMENTS AND/OR ADMINISTRATIVE SANCTIONS. Source: Provider Billing Manual 27.2.3
Morphine Milligram Equivalents (MME) Information/Examples
Higher doses of opioids are associated with a higher risk of overdose and death. Even relatively low dosages (20-50 MME per day) increase risk.1
Examples of MME calculations/day include:
- 10 tablets per day of hydrocodone/acetaminophen 5/325 = 50 MME/day
- 6 tablets per day of hydrocodone/acetaminophen 7.5/325 = 45 MME/day
- 5 tablets per day of hydrocodone/acetaminophen 10/325 = 50 MME/day
- 2 tablets per day of oxycodone 15 mg = 45 MME/day
- 3 tablets per day of oxycodone 10 mg = 45 MME/day
- 10 tablets per day of tramadol 50 mg = 50 MME/day
- 1 patch per 3 days of fentanyl 25mcg/hr = 60 MME/day
A link with more information regarding MME calculations is https://www.cdc.gov/drugoverdose/pdf/calculating_total_daily_dose-a.pdf.
*Partial Filling of Schedule II Medication: Per the Alabama State Board of Pharmacy website, there has been a change in federal law regarding partial filling of Schedule II controlled substance (CS). The Comprehensive Addiction and Recovery Act (CARA) of 2016 passed the United States Senate and was signed into law on July 22, 2016. CARA allows pharmacists to partially fill Schedule II CS. According to CARA, a prescription may be partially filled if: it is written and filled according to state and federal law; the partial fill is requested by the patient or prescribing practitioner; and the total quantity dispensed does not exceed the quantity prescribed. Remaining portions of partially filled prescriptions must be filled within 30 days of the original written prescription date. There is no single specified way to fill or bill prescriptions under the CARA update.2
1 https://www.cdc.gov/drugoverdose/prescribing/guideline.html
2 http://www.albop.com/FAQ.aspx
Override Requests
Pharmacy override requests for quantities exceeding the maximum days’ supply limit or MME limit may be submitted to Health Information Designs (HID). Please see the Pharmacy Override External Criteria instructions for information about override requirements at: http://medicaid.alabama.gov/content/9.0_Resources/9.4_Forms_Library/9.4.13_Pharmacy_Forms.aspx.
The Override Request Form is to be used by the prescriber or the dispensing pharmacy when requesting an override. The form can be found at: http://medicaid.alabama.gov/content/9.0_Resources/9.4_Forms_Library/9.4.13_Pharmacy_Forms.aspx.
Providers requesting overrides by mail or fax should send requests to:
Health Information Designs (HID)
Medicaid Pharmacy Administrative Services
P. O. Box 3210 Auburn, AL 36832-3210
Fax: 1-800-748-0116
Phone: 1-800-748-0130
Incomplete requests or those failing to meet Medicaid criteria will be denied. If the prescriber believes medical justification should be considered, the prescriber must document this on the form or submit a written letter of medical justification along with the override form to HID. Additional information may be requested. Staff physicians will review this information.
Any policy questions concerning this provider ALERT should be directed to the Pharmacy Program at (334) 242-5050. Questions regarding override procedures should be directed to the HID help desk at 1-800-748-0130.