CMS: New Medicare Part D Policies to Address Opioid Epidemic

April 03, 2019 - CMS has introduced new Medicare Part D patient safety policies that will address the opioid epidemic while still preserving medically necessary access to pain management therapies.

The new policies will include improved safety alerts at the pharmacy for Part D beneficiaries filling their initial opioid prescription or receiving high doses of prescription opioids. Medicare drug plans will also perform additional safety checks by sending pharmacies an alert to review certain opioid prescriptions before they’re filled.

“While illicit opioid use is part of the epidemic, prescription opioids provided by physicians can also contribute to the crisis when not used carefully,” Kimberly Brandt, Principal Deputy Administrator for Operations, wrote in a recent blog post.

“As Medicare pays for a significant amount of prescription opioids, we strive to ensure appropriate stewardship of these medications that can provide a medical benefit but also carry a risk for our beneficiaries.”

Pharmacy safety alerts may occur if a Part D beneficiary receives opioid prescriptions that exceed a certain amount. Beneficiaries may also be limited to a 7-day supply or less for acute pain if they haven’t recently taken opioids, and pharmacies may receive safety alerts if Part D beneficiaries are taking opioids and benzodiazepines at the same time.

“CMS’s goal with this policy is to reduce the potential for chronic opioid misuse through closer management of opioid naïve patients,” CMS wrote.

“Clinical evidence cited by the Centers for Disease Control and Prevention (CDC) found that opioid use for acute pain is associated with long-term opioid use and that a greater amount of early opioid exposure is associated with greater risk for long-term use.”

If the prescription cannot be filled as written, and a provider believes the patient will need more than a 7-days’ supply, the provider can request a coverage determination on behalf of the beneficiary.  

“It’s important to note that these new policies are not ‘one size fits all,’ and are deliberately tailored to address distinct populations of Medicare Part D prescription opioid users,” Brandt said.

“These interventions do not apply to residents of long-term care facilities, beneficiaries in hospice, palliative, or end-of-life care, and beneficiaries being treated for active cancer-related pain.”

The new policies will also enable Part D plans to implement drug management programs, which will serve to help beneficiaries use opioids safely. Beneficiaries that receive opioids from multiple doctors and pharmacies may need to receive their prescriptions from specific providers to ensure appropriate care coordination.

“The goal of drug management programs is better care coordination for safer use. Potential at-risk patients are identified by their opioid use which involve multiple doctors and pharmacies. Therefore, these are patients who could potentially abuse or misuse prescription drugs,” CMS said.

“The care coordination safety alert is a proactive step to give prescribers more information, and if warranted, to encourage prescribers to emphasize opioid overdose risk and prevention with their patients, especially if the patient is receiving prescription opioids from multiple prescribers or pharmacies.”

Health plans will notify beneficiaries if drug management programs limit medication access, and beneficiaries and doctors will have the right to appeal.

These new policies will build on CMS’s ongoing efforts to address the opioid epidemic. In June 2018, the agency issued a roadmap outlining its strategies to curb opioid misuse. The three-pronged approach focuses on opioid use disorder prevention, treatment, and data utilization to target appropriate patient populations.

CMS is also leveraging health data to identify fraud and waste among patients, as well as monitor trends and assess the effectiveness of treatment and prevention solutions.

With these new policies, CMS will enhance its efforts to reduce opioid abuse and addiction.

“The new Medicare Part D opioid policies encourage collaboration and care coordination among Medicare drug plans, pharmacies, prescribers, and patients, in order to improve opioid management, prevent opioid misuse, and promote safer prescribing practices,” Brandt concluded.  

“CMS continues to be committed to addressing the opioid crisis and helping our beneficiaries use prescription opioid pain medications more safely.”