Opioid management program and pain management alternatives

Opioid management program for Commercial plans 

Opioid painkillers provide needed relief to those with acute or chronic pain. But given their potential for harm, and the very real–and pervasive–problem of misuse and abuse, ensuring appropriate use is more critical now than ever before. Our standard opioid management program is aligned with the “Guideline for Prescribing Opioids for Chronic Pain” issued by the Centers of Disease and Prevention (CDC) in March 2016 and contains the following features:

Inappropriate Drug Therapy Combinations
The pharmacy may need to contact the prescriber to resolve these issues:

  • Opioids & Medication Assisted Treatment (MAT): reject for an opioid claim secondary to a MAT drug (includes only buprenorphine-combination products)
  • Opioids & Benzodiazepine: reject for an opioid drug if the member has an existing claim for a benzodiazepine and vice versa
  • Opioids & Prenatal Vitamin: reject for an opioid drug if the member has an existing claim for a prenatal vitamin claim and vice versa

Inappropriate opioid quantities or dosing
The pharmacy may need to contact the prescriber to resolve these issues:

  • Members already on opioids: reject for a cumulative Short Acting Opioid/Long Acting Opioid dose check for >90 MME*/day
  • Members new to opioids: reject for a cumulative Short Acting Opioid/Long Acting Opioid dose check for >50 MME*/day
  • Members new to opioids: reject for Short Acting Opioid prescriptions for >7 day supply
  • Members new to opioids: reject for a Long Acting Opioid with no paid claim for a Short Acting Opioid

The following requires prior authorization from the prescriber:

  • Members already on opioids: Prior Authorization required for a cumulative Short Acting Opioid/Long Acting Opioid dose check for >180 MME*/day

Therapeutic Dose Limit
The pharmacy may need to contact the prescriber to resolve this issue:

  • Cumulative acetaminophen dose check (with opioid-containing drugs) >4 grams/day (reject)

Refill Threshold

  • This edit narrows the refill window for Schedule II-V controlled drugs to a 90% threshold at retail pharmacy and 80% at mail order.

Opioid Management Edits
The following require prior authorization from the prescriber if exceeding the limit:

  • Members new to opioids: Short Acting Opioids maximum 50 MME*/day
  • Members new to opioids: Short Acting Opioids 7 days supply limit
  • Members already on opioids: Short Acting Opioids maximum 90 MME*/day. 
  • All members: use of Short Acting Opioids required before Long Acting Opioids
  • All members: Quantity Limits on all Long Acting Opioids based on FDA maximum dosing frequency (i.e. once daily)
  • All members: Maximum 2 opioid fills within a 60-day time period

Pediatric (<19 years of age) Edits 
The following require prior authorization from the prescriber if exceeding the limit:

  • All pediatric members: PA required for all opioid containing cough and cold medications
  • Pediatric members new to opioids: 3 days supply limit

When patients fill a prescription for an opioid (a covered drug that is a narcotic substance contained in U.S. Drug Enforcement Administration Schedule II), they may choose to obtain a fill in a lesser quantity than the full amount prescribed.  If they do, they may then choose to later obtain the remainder of the prescribed fill.  They will not be responsible for any copayment amount beyond the amount that would normally apply if they obtained the entire fill at once.

Opioid management program for Medicaid/MassHealth ACO plans 

Effective April 1, 2023, Fallon Health ACO plans will begin to follow the MassHealth Unified Formulary. All Massachusetts Medicaid managed care organizations (MCOs) will follow MassHealth’s pharmacy drug coverage and criteria. ACOs are however allowed to have different dose thresholds for opioid dosages.

Please refer to the table below for Fallon Health ACO initiatives, thresholds and dose limits.

Edit

Summary

Drug-drug interaction

Soft edit: drug-drug interaction between opioids and benzodiazepines

Drug-drug interaction

Soft edit: concurrent use of opioids and medication assisted treatment for addiction (MAT)

Drug-drug interaction

Soft edit: concurrent use of opioids and prenatal vitamins will trigger soft edit reject

Drug-drug interaction

Soft edit: concurrent use of opioids and antipsychotics will trigger soft reject edit

180 MME limit for Opioid regimens

Prior authorization will be required if a member’s opioid regimen exceeds 180 MME/day. Members with sickle cell disease, cancer, or a history of a diagnosis indicating palliative care treatment are exempt.

7 day supply initial fill

Treatment naïve member (no opiate claims in the last 120 days) will have a soft reject if attempting to fill > 7 day supply.  Members with sickle cell disease, cancer, or a history of a diagnosis indicating palliative care treatment are exempt.

Duplicate Long-Acting Opioids

For any combination of 2 or more long-acting opioids, if there is greater than 2 months of duplicate claims in a member’s claims history the opioid will require prior authorization

Duplicate Short-acting Opioids

For any combination of 2 or more short-acting opioids, powders, and combination products, if there is greater than 2 months of duplicate claims in a member’s claim’s history

Concurrent Therapy with Opioid Dependence Agents

Prior authorization is required if a member is stable on any buprenorphine product used for substance use disorder and is attempting to fill a long-acting opioid (for any length of time), a short-acting opioid for more than a 7 day supply, or short-acting opioid(s) for more than 7 days of therapy in the last 30 days.
“Stability” is defined as: 1. Buprenorphine/naloxone film or tablet, Zubsolv, or Bunavail: 60 days of therapy within the last 90 days 2. Probuphine (buprenorphine implant): history in the past 210 days. 3. Sublocade: ≥ 56 days of therapy in the last 84 days

Quantity Limit & Quantity limit for short acting opioids without long acting opioids

Claims for specified short-acting opioids over a dosage limit (120MME) and being used as monotherapy (no claim for a long acting opioid agent within the last 30 days) will reject at the pharmacy as prior authorization required.

Concurrent Opioid and Benzodiazepines

Hard Edit: Drug – 60 day overlap of opioid and benzo within last 90 days; one-way edit where only benzo will reject.

Therapeutic Dose

Hard Reject: Cumulative acetaminophen dose check (APAP); > 4 gram of acetaminophen containing products will trigger a hard reject edit

Therapeutic Dose

Hard Reject: Cumulative dose check of aspirin (>4GM) and ibuprofen (>3.2GM).

Concurrent Therapy

Concurrent use of opioids and MAT (medication assisted treatment for addiction); opioid post MAT (e.g. Suboxone) will trigger soft reject edit

 

Pain management alternatives to opioid products

If you are interested in pain management alternatives to opioid products for your patients, there are many non-opioid medications and treatments available. These include, but are not limited to, those listed below.

Non-opiate medication treatment options (Please note that some medications require PA or may have other utilization management restrictions):

  • NSAIDs
  • Topical Analgesic
  • Cox-II Inhibitors
  • Skeletal Muscle Relaxants
  • Anti-Depressants
  • Anti-Convulsants
  • Corticosteroids

Please refer to our formulary for further information about our prescription drug formulary and prior authorization requirements.

Non-medication treatment modalities:

  • Chiropractic care
  • Physical therapy services
  • Behavioral health providers with pain management-related specialties, such as cognitive behavioral therapy, pain management and treatment of chronic pain.

These services may require prior authorization or may be subject to benefit limitations or may not be covered for all plans.

Additional medications and treatments are available which may also serve as pain management alternatives to opioid products. These include other medications, certain other types of therapies, treatment by certain types of non-behavioral health specialists, certain types of surgery, and certain types of injections.

*Morphine Milligram Equivalents are a way to compare different opioid medications based on their strength as compared to morphine