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Opioid Awareness

As a healthcare partner to the community of Philadelphia--where the opioid crisis has affected thousands of families—we are committed to tackling the city’s opioid epidemic along with your help. But there’s a lot of work to be done.

In 2016, Philadelphia had the second-highest rate of drug overdose deaths among the nation's 44 counties with over 1 million residents: 46 deaths per 100,000 residents, with most attributed to the misuse of opioids.*

To reduce opioid abuse, HPP has adopted initiatives, guidelines and policies to increase safe opioid prescribing and help ensure appropriate treatment for our members, providers, and the community at large.

Health Partners Medicare Changes for 2019

To align with the Centers for Medicare & Medicaid Services (CMS), CMS is requiring all Medicare Part D plans, including Health Partners Medicare, to comply with new opioid prescribing guidelines beginning in 2019. These changes will impact nearly every provider who writes prescriptions for opioids and nearly every patient who receives a prescription. Changes include

  • Denial of prescriptions greater than a seven-day supply for patients new to opioid therapy:
    • "New to opioid therapy" is defined as no opioid filled in the previous 120 days.
    • Approval of these rejections will require an exception approval from Health Partners Medicare.
    • Rejections will not be overridden during a patient’s transition period.
    • Patients new to Medicare will also be subject to this rejection.
  • Denial of prescriptions that exceed certain milligram morphine equivalent (MME) doses:
    • 90 mg MME; may be overridden by the dispensing pharmacist after consultation with the prescriber.
    • 200 mg MME; an exception approval with Health Partners Medicare is required to override
    • If opioid prescriptions are filled at three or more pharmacies and written by three or more prescribers, and the opioid therapy exceeds these doses, they will be denied.
  • Rejection of co-administration with benzodiazepines:
    • Co-administration of opioids with benzodiazepines, especially with high doses and/or prolonged use, increases the risk of patient mortality.
    • This may be overridden by the dispensing pharmacist after consultation with the prescriber.
  • Duplicate long-acting opioids:
    • Two or more long-acting opioids taken concurrently show little to no evidence of increased efficacy while increasing risk of morbidity and mortality
    • This may be overridden by the dispensing pharmacist after consultation with the prescriber
  • Patient "lock-in":
    • When identified through case management, patients at high risk for opioid overuse may be "locked in" to a specific pharmacy and/or prescriber.
    • A pharmacy and prescriber agreement is required.

Health Partners (Medicaid)

Medication-Assisted Treatment (MAT) for opioid addiction

The Pennsylvania Department of Human Services (DHS) has lifted prior authorizations for MAT to ensure unrestricted access to treatment for members seeking help for addiction.

Prior authorization is not required

  • Denial of prescriptions greater than a seven-day supply for patients new to opioid therapy:
  • Buprenorphine-naloxone sublingual tablets
  • Buprenorphine tablets
  • Vivitrol®, covered by HPP in dosages of one injection every 28 days

Prior authorization is required

  • Opioid prescriptions that exceed a 90 MME threshold
  • Suboxone® film strips
  • Buprenorphine in pregnant women and in patients also taking benzodiazepines, opioids, or skeletal muscle relaxants
  • Prescriptions that exceed a daily dose limit of 16 mg a day
  • For under 21, all opioid containing medications (formulary and non-formulary) when the prescription exceeds a 3-day supply, and if more than one opioid containing medication is prescribed within 365 days
  • For patients 21 and older, all opioid containing medications (formulary and non-formulary) when the opioid prescription exceeds a 5-day supply, and if more than one opioid containing medication is prescribed within 180 days.

Note: Patients who are being treated for cancer or sickle cell anemia, and those on hospice care, are exempt from this prior authorization criteria.

Alternative therapies

Opioids are not the only first-line therapy for chronic pain outside of active cancer treatment, palliative care and end-of-life care. Evidence suggests that non-opioid treatments can provide relief to those suffering and are safer. These therapies include:

  • Non-addictive painkillers like Tylenol® and Advil®
  • Physical and massage therapy
  • Acupuncture
  • Aqua therapy
  • Nerve blocks
  • Other non-addictive pain relief methods

Please note that products containing buprenorphine should not be used for the treatment of pain.

Resources

Utilize these tools and resources to help manage your patients.

For more information, call HPP's Pharmacy department at 215-991-4300, our Provider Services Helpline at 1-888-991-9023 (M-F, 9 a.m. to 5:30 p.m.) or reach out to your Network Account Manager (NAM).

* Source: Centers for Disease Control and Prevention, Multiple Cause of Death Data, 2016