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CMS Announces New Protections to Combat Opioid Crisis

February 02, 2018

The Centers for Medicare & Medicaid Services (CMS) released proposed changes for 2019, which are aimed at combatting the opioid crisis by strengthening patient-doctor-plan communication.

The new action would combat the nation’s opioid epidemic through oversight of programs that have successfully reduced opioid overutilization by Medicare Part D enrollees. The agency is developing policies that would give health plans additional tools to manage chronic overuse among beneficiaries by ensuring patient-doctor-plan communication regarding opioid use.

CMS’ Medicare Part D opioid overutilization policy has evolved to address prescription opioid overuse from a medication safety perspective, while preserving beneficiary access to medically necessary drug regimens. Given the urgency and scope of the continuing national prescription opioid epidemic, CMS will propose new strategies to more effectively address this issue for patients in Part D, including: 

  • Identifying high-risk beneficiaries who use “potentiator” drugs in combination with prescription opioids to ensure that plans provide appropriate case management
  • Implementing technical revisions to the Pharmacy Quality Alliance (PQA) measures used to evaluate Part D sponsors’ progress in combatting the opioid crisis, and consideration of a new PQA measure, Concurrent Use of Opioids and Benzodiazepines
  • Expecting all sponsors to implement hard formulary-level cumulative opioid safety edits at point-of-sale (POS) at the pharmacy at 90 morphine milligram equivalent, with a seven-day supply allowance
  • Implementing a supply limit for initial fills of prescription opioids (e.g., seven days) for the treatment of acute pain with or without a daily dose maximum
  • Expecting all sponsors to implement soft POS safety edits (which can be overridden by a pharmacist) based on duplicative therapy of multiple long-acting opioids, and request feedback on concurrent prescription opioid and benzodiazepine soft edits

CMS is accepting comments about the proposed Advance Notices and Draft Call Letter through March 5, 2018.

HAP welcomes this federal effort to align program policy to better respond to the nation’s opioid crisis. HAP continues to monitor and share information about state and national efforts to fight substance use disorder and the opioid epidemic, including legislative and regulatory policy developments and treatment strategies, and advocate for flexibility to address the public health crisis.

For more information about HAP’s work to combat the opioid crisis, contact Michael J. Consuelos, MD, HAP's senior vice president, clinical integration.

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