Effective December 2, 2019, the Alabama Medicaid Agency will implement hard edits on cumulative daily MME claims exceeding 200 MME/day. A phase-in period for claims exceeding 150 MME/day, but less than 200 MME/day, will also be implemented.
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
IMPORTANT: Only when the override is denied will the excess quantity above the maximum unit limit be deemed a non-covered service. Then 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
Any policy questions concerning this provider ALERT should be directed to the Pharmacy Program at (334) 242-5050.