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New Opioid Use Edits Effective 1/1/2017

Effective January 1, 2017, Health Partners Plans (HPP) will implement new edits on opioid use by our Medicare members, to comply with new regulations from the Centers for Medicare and Medicaid Services (CMS).

 

Starting January 1, an HPP Medicare member’s opioid prescription will be rejected if:

1) The member’s cumulative dose for opioids across all prescriptions in a given month exceeds a certain limit of an equivalent morphine dose;

and

2) The member has filled opioids at three or more different pharmacies;

and

3) The member has opioid prescriptions written by three or more different prescribers.

 

If all three prescription conditions occur, the prescription will reject as described below:

  • If the cumulative dose exceeds 120 mg of morphine equivalents, the prescription will reject at the pharmacy.  

– This rejection can be overridden by the dispensing pharmacist.

  • If the cumulative dose exceeds 240 mg of morphine equivalents, the prescription will reject at the pharmacy.

– This rejection cannot be overridden by the pharmacist.

– A coverage determination is needed.

 

This edit only applies to Health Partners Medicare members; members who are in hospice or have a cancer diagnosis are exempt.

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