Opioid Reduction & Authorization Criteria

In an effort to support and promote safe opioid use and appropriate pain management, Samaritan Health Plans is implementing new authorization criteria and medication limits following CDC guidelines for our Samaritan Choice Plans and Samaritan Employer Group Plans members.

• Short-Acting Opioid (SAO) medication (brand or generic product)
  • New to Therapy: Member Limits on Short Acting Opioids
    • Members who are new to opioid therapy (no opioid in their most recent 120-day claims history), will be limited to a maximum of 49 morphine-equivalent mg per day of an opioid medication per fill, max. 7-day supply, limit 2 fills within 60-day timeframe.
  • Treatment Experienced Member Limits on Short Acting Opioids
    • Members who are NOT new to therapy (have opioid fills in their most recent 120-day claims history), will be limited to a maximum of 90 morphine-equivalent mg per day of an opioid medication per fill, and subject to 2 fills within a 60-day timeframe.
• Long-Acting Opioid (LAO) medication (brand or generic product)
  • Plan will require a Prior Authorization for all long acting opioids, including new starts, which will require step therapy with a short acting opioid prior to starting a long acting opioid beginning 09/01/18
• Age-based Prior Authorizations for Antitussive
  • Prior Authorization will be required for all members under 12 years of age
  • Prior Authorization will be required for members between 12-17 years of age that have a medication for asthma, COPD, or obesity in the most recent 365 days
• Antitussive Quantity Limits for ALL AGES
  • Liquid formulations of antitussives will be limited to a maximum of 240ml per fill
  • Tablet/capsule formulations will be limited to a maximum of 7-day supply fill
  • Additional quantities over the maximum daily dose will require a Prior Authorization
  • A maximum of 2 fills (liquid or tablet/capsule) within a 60-day period

Please Note: Edits will first screen the past 365 days of a member’s profile for oncology drugs and will not require a prior authorization if one is found.

A Prior Authorization May Be Pursued If Clinically Necessary

Additional treatment/increased quantities will be approved with a PA when one of the following criteria are met:

• Diagnosis of Cancer, or
• Patient is receiving opioids as part of end of life care, or
• All of the following:
  • The prescriber certifies that there is an active treatment plan that includes but is not limited to a specific treatment objective and the use of other pharmacological and nonpharmacological agents for pain relief as appropriate, and
  • The prescriber certifies that there has been an informed consent document signed and an addiction risk assessment has been performed, and
  • The prescriber certifies that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists

• Short-Acting Opioid (SAO) medication (brand or generic product)
  • New to Therapy: Member Limits on Short Acting Opioids
    • Members who are new to opioid therapy (no opioid in their most recent 120-day claims history), will be limited to a maximum of 49 morphine-equivalent mg per day of an opioid medication per fill, max. 7-day supply, limit 2 fills within 60-day timeframe.
  • Treatment Experienced Member Limits on Short Acting Opioids
    • Members who are NOT new to therapy (have opioid fills in their most recent 120-day claims history), will be limited to a maximum of 90 morphine-equivalent mg per day of an opioid medication per fill, and subject to 2 fills within a 60-day timeframe.
• Long-Acting Opioid (LAO) medication (brand or generic product)
  • Plan will require a Prior Authorization for all long acting opioids, including new starts, which will require step therapy with a short acting opioid prior to starting a long acting opioid beginning 09/01/18
• Age-based Prior Authorizations for Antitussive
  • Prior Authorization will be required for all members under 12 years of age
  • Prior Authorization will be required for members between 12-17 years of age that have a medication for asthma, COPD, or obesity in the most recent 365 days
• Antitussive Quantity Limits for ALL AGES
  • Liquid formulations of antitussives will be limited to a maximum of 240ml per fill
  • Tablet/capsule formulations will be limited to a maximum of 7-day supply fill
  • Additional quantities over the maximum daily dose will require a Prior Authorization
  • A maximum of 2 fills (liquid or tablet/capsule) within a 60-day period

Please Note: Edits will first screen the past 365 days of a member’s profile for oncology drugs and will not require a prior authorization if one is found.

A Prior Authorization May Be Pursued if Clinically Necessary

Additional treatment/increased quantities will be approved with a PA when one of the following criteria are met:

• Diagnosis of Cancer, or
• Patient is receiving opioids as part of end of life care, or
• All of the following:
  • The prescriber certifies that there is an active treatment plan that includes but is not limited to a specific treatment objective and the use of other pharmacological and nonpharmacological agents for pain relief as appropriate, and
  • The prescriber certifies that there has been an informed consent document signed and an addiction risk assessment has been performed, and
  • The prescriber certifies that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists

IHN-CCO Opioid Benefit Change Timeline

	Benefit Changes
April 2016	Opioid quantity limitation — 240 per 30 days Member notification letter Provider clinic notification email
May 2016	Opioid quantity limit enacted (5/2/2016) Quantity limit exception criteria enforced
October 2016	Opioid quantity limitation- 180 per 30 days Member notification letter Provider clinic notification email
November 2016	Opioid quantity limit enacted (11/15/2016) Quantity limit exception criteria enforced
December 2016	Provider taper plan and >120 MED restriction notification (12/12/2016) Member notification of taper plan requirement and >120 MED restriction (on or before 12/31/2016)
January 2017	Taper plans should be submitted to IHN-CCO by 01/15/2017 Please note: OHA has determined that coverage of opioids for back pain and related DX will be terminated 01/01/2018; tapering of opioids should occur during 2017
February 2017	Members on opioids limited to 120 MED for chronic, non-cancer pain >120 MED restriction for opiate prescriptions (02/01/2017) Denial of opioid benefits for members without taper plans in place
July 2017	Provider taper plan and >90 MED restriction notification Member notification of taper plan requirement and >90 MED restriction
September 2017	Members on opioids limited to 90 MED for chronic, non-cancer pain >90 MED restriction for opiate prescriptions 09/01/2017 Denial of opioid benefits for members without taper plans in place
January 2018	Opioid coverage for chronic back and spine conditions terminated 01/01/2018
September 2018	New to Therapy: Member Limits on Short Acting Opioids Treatment Experienced: Member Limits on Short Acting Opioids Plan will require a Prior Authorization for all long acting opioids, including new starts and required to step through short acting agent beginning 09/01/18 Age-based Prior Authorizations for Antitussive Antitussive Quantity Limits for ALL AGES

If you have questions regarding specific opioid benefit changes, please contact Customer Service.

Changes effective Jan. 1, 2019. 

CMS has significantly expanded its oversight of Medicare Part D plans to ensure compliance with requirements that protect beneficiaries and can help prevent and address opioid overutilization. In response to the Centers for Medicare & Medicaid Services (CMS) Samaritan Advantage Health Plans has placed safety limits on opioid medications.

Days Supply Limits on Opioid Prescriptions

• 7-day supply limit for opioid naïve patients: Part D plans are required to implement a safety edit to limit initial dispensing to a supply of 7 days or less. This policy will affect Medicare members who have not filled an opioid prescription recently (within the past 120 days) when they present a prescription at the pharmacy for an opioid pain medication for greater than a 7-day supply. This rejection is a hard reject that cannot be overridden.
  • If a prescriber believes that an opioid naïve patient will need more than a 7-day supply initially, the provider can proactively request a coverage determination on behalf of the member attesting to the medical need for a supply greater than 7 days.
• 30-day opioid dispensing limit: Opioid drug claims will be limited to a 30-day supply unless the claim is for an opioid naïve patient as described above. This rejection is a hard reject that cannot be overridden.

Real-Time Safety Alerts at the Time of Pharmacy Dispensing

• Safety edit when exceeding 90 MED: This policy will affect Medicare members when they present an opioid prescription at the pharmacy and their cumulative morphine equivalent dose (MED) per day across all of their opioid prescription(s) reaches or exceeds 90 MED. The fill of a prescription that brings a member to the cumulative threshold of 90 MED or greater will trigger an alert.
  • The pharmacist should consult with the prescriber, document the discussion, and if the prescriber confirms intent, use an override code that indicates the prescriber has been consulted.
• Safety edit when exceeding 200 MED: A safety edit will trigger when a Medicare member presents an opioid prescription at the pharmacy and their cumulative morphine equivalent dose (MED) per day across all of their opioid prescription(s) reaches or exceeds 200 MED. Authorization will be required to exceed 200 MED.
• Opioid/Medication Assisted Treatment (MAT) (Buprenorphine) (Soft Reject): check if an opioid is filled after a paid MAT claim.
• Opioid/Benzodiazepine (Soft Reject): check for concurrent opioid and benzodiazepines use.
• Opioid/Prenatal vitamin (Soft Reject): check for concurrent opioid and prenatal vitamin use.
• Duplicate Therapy- Long Acting Opioids (Soft Reject): checks for overlapping claims within the last 120 days where the member is on two long acting opioids concurrently.
• Therapy Dose Check- Acetaminophen (Soft Reject): checks for excessive use, early refills, or stockpiling of acetaminophen, which includes combo drugs, such as APAP/opioids.
  • The Pharmacist may override a soft reject with a list of predefined codes to result in claim payment if clinically appropriate.

Important Exclusions

Residents of long-term care facilities, those in hospice care, patients receiving palliative or end-of-life care, and patients being treated for active cancer-related pain are excluded from these interventions.

For a comparison of opioid doses, a tool was developed to equate the many different opioids into one standard value. This standard value is based on morphine and its potency, referred to as morphine equivalent dose (MED).  Knowing the MED helps determine if the patient’s opioid doses are excessive and is useful if converting from opioid to another.

MED can be calculated using a morphine opioid conversion chart. Steps to calculate MED:

• Opioid daily dose = Quantity written/Days supply
• MED = (opioid daily dose) x (dosage strength) x (MED conversion factor)
• Example: Oxycodone 5mg, 1 tab po four times daily as needed #120
  • Opioid daily dose = 120 tablets/28 days = 4 tabs/day
  • MED = (4 tabs/day) x (5mg/tab) x (1.5) = 30mg/day MED

	Conversion Factor
Codeine	0.15
Fentanyl patches	2.4
Hydrocodone	1
Hydromorphone	4
Methadone	4 (may be dose dependent)
Morphine	1
Oxycodone	1.5
Oxymorphone	3
Tapentadol	0.4
Tramadol	0.2

In March 2016, the Centers for Disease Control and Prevention (CDC) developed the new Guideline for Prescribing Opioids for Chronic Pain to help primary care providers make informed prescribing decisions and improve patient care for those who suffer from chronic pain (pain lasting more than 3 months) in outpatient settings. The CDC recommends re-assessing opioid treatment before increasing dosage to 50 MED or more per day. This amount was based on the most recent scientific evidence regarding the association between opioid dosage and overdose risk.

Each plan’s formulary contains many non-opioid alternatives such as: NSAIDs (meloxicam, naproxen, indomethacin, diclofenac, etc.), anticonvulsants (gabapentin, carbamazepine), muscle relaxants (baclofen, tizanidine), topical agents (lidocaine 5% patch & ointment, diclofenac 1% gel). Please consult the drug formulary for the member’s plan for current alternatives.

Please call Customer Service for current benefit coverage options and limitations at 1-888-435-2396, 8 a.m. to 6 p.m., Mon.–Fri.