Effective July 1, 2021, The Alliance will be implementing the following prospective opioid safety edits when pharmacy claims are processed through Pharmacy Benefit Manager, MedImpact. This is to comply with CMS 2482-Final Rule regarding the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act.
Point of sale (POS) safety edits provide real-time information to the pharmacist prior to the prescription being dispensed to a patient, but do not necessarily prevent the prescription from being dispensed.
Exclusions:
- Residents of Long-term care
- Cancer or sickle cell disease pharmacy claims history within the past 180 days
- Prescriptions from following specialists: Oncology/Hematology, Hospice, Palliative Care, Pain Medicine, Surgery, Hospitalist
- Opioid Cumulative Dosing and Opioid Naïve Day Supply Limitation Safety Edits only
Drug Utilization Review (DUR)
In order to override the rejections (see next page), the pharmacist may evaluate and submit the applicable DUR codes on the pharmacy claim. Certain opioid safety programs also allow for submission of DUR codes following consultation with the prescriber. For these instances, the pharmacist should document the discussion with the prescriber who determined the opioid regimen is clinically appropriate.
Examples of When DUR Codes Can Be Used:
Hospice, Palliative Care, Cancer, Prescriber Approval, Medication Review by Pharmacist
Special Note: If the pharmacy cannot or will not enter the DUR codes, the claim will deny and follow the standard prior authorization process.
| Opioid Naïve Day Supply Limitation | This edit limits the day supply of the first fill of opioids to 7 day supply for opioid naïve members. Opioid naïve members are members who have not recently filled an opioid (past 60 days). |
| Opioid Naïve Subsequent Fill Limit | This edit denies an incoming claim for an opioid when an opioid naïve member exceeds 2 fills in 30 days following the initiation of opioid therapy. |
| Duplicative Long-Acting Opioid Therapy | This program denies an incoming claim for a long-acting opioid drug when it overlaps with another long-acting opioid drug with a different active ingredient by a different prescriber. |
| Opioid Cumulative Dosing | This program will deny an incoming opioid claim(s) that meets or exceeds a member’s daily cumulative morphine milligram equivalent (MME) limit of 90 MME, if the prescriptions are written by 2 or more prescribers. |
| Opioid-Buprenorphine Concurrent Use | This edit denies an incoming opioid claim when it overlaps with a claim for buprenorphine used for medication assisted treatment (MAT). |
| Opioid-Benzodiazepine Concurrent Use | This program denies an incoming claim when a member has active overlapping claims for both an opioid and a benzodiazepine by different prescribers. This edit is bi-directional so either drug will stop if there is active overlapping claim history of the other drug. |
| Opioid-Antipsychotic Concurrent Use | This program denies an incoming claim for an opioid when a member has an active claim(s) for an antipsychotic by a different prescriber. This edit is one-directional and will deny the opioid claim only. |
| Prospective DUR (ProDUR) Naloxone Alert | This alert sends an informational message to the pharmacy when a member has concurrent use of any of the drug combinations that could indicate the member is at high risk for overdose:
The message will include recommendation to co-dispense or obtain a prescription for naloxone. |
Please contact your Provider Relations Representative with any questions at (800) 700-3874 ext. 5504.
