Start of New Year = Opioid Plan Rejects

PAAS National® analysts receive numerous calls at the start of the new year looking for guidance on opioid plan rejects. With the new year, many patients may be on a new Medicare Part D plan. Opioid prescriptions processed previously with no issues, may now reject at point-of-sale on the new plan.

With the opioid crisis on the rise, CMS acted in 2018 to closely monitor opioid use and safety of patients. Medicare Part D plans were required to implement opioid policies and work together with patients, prescribers, and pharmacies with this monitoring. These policies included real-time safety alerts at the pharmacy’s point-of-sale.

Here are the four Medicare Part D opioid safety alerts:

  1. Seven-day supply for opioid naïve patients
  2. Exceeding maximum dose of morphine to 90 MME (morphine milligram equivalent), including cumulative dosing
  3. Concurrent use of opioid and benzodiazepine
  4. Optional alert can be implemented by plan for cumulative opioid daily dose of 200 MME

In August of 2022, CMS through the Medical Learning Network (MLN) published A Prescriber’s Guide to Medicare Prescription Drug (Part D) Opioid Policies. This guide offers guidance to both prescribers and pharmacies for patients using opioid medications. Pharmacies should note, alerts that cannot be resolved at point-of-sale may require providing patients with a copy of the CMS-10147 Medicare Prescription Drug Coverage and Your Rights form. This form provides instructions for patient to work with their prescriber and their Medicare plan to expedite coverage for their medication.

Pharmacies have an obligation to

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follow plan alerts and guidelines for the safety of patients. Bypassing these restrictions not only put claims at risk of recoupment, but further scrutiny of your controlled substance dispensing practices. Split billing opioid prescriptions (i.e., billing part to insurance and cash payment for the remainder) is considered bypassing. When claims are not accurately billed to the Medicare D plan, proper monitoring cannot be done. PAAS does not recommend pharmacies split bill prescriptions to resolve rejects.

PAAS Tips:

  • Call plan for overrides or prior authorization when appropriate
  • Consult with prescribers about safety alerts and possible resolutions, e.g. changing medication or completing prior authorization paperwork
  • Prescribers unwilling to work with the pharmacy could be a red flag for the clinical appropriateness of their prescribing
  • PBMs can monitor and flag prescriptions that bypass plan limits
  • Charging the patient cash and not submitting claims could be considered non-compliance with the provider manual and could lead to network termination
  • Involving the patients in the resolution process may be necessary
  • See the CMS Medicare Part D Opioid Policies: Information for Pharmacists

Dana Westberg, CPhT