Opioids

CMS Draft Call Letter Released; Opioid Use Worrisome

Opioids remain a concern for officials at the Centers for Medicare and Medicaid Services (CMS). The agency has announced that addressing the epidemic – addiction, misuse, overdose and death – is one of its top priorities, and that officials have made big changes to 2019 Medicare Part D Opioid Prescribing Policies as a result.

More recently, CMS included in its Medicare Advantage (MA) and Part D draft call letter for 2020 a proposal to implement provisions of the federal SUPPORT for Patients and Communities Act that that require coverage of opioid addiction treatment programs, including medication-assisted treatment. The letter also encourages health plans to lower the out-of-pocket cost of Naloxone, which can quickly treat a narcotic overdose in an emergency, and, just as importantly, encourage doctors to prescribe the drug alongside opioids just in case. Alternative therapies also are encouraged. CMS says it plans to increase surveillance of opioid misuse with its overuse and misuse monitoring system.

The final version of the call letter will be released in early April. The initial draft also includes:

Changes to Supplemental Benefits

CMS is proposing that Medicare Advantage plans offer supplemental benefits outside the primary health plan to patients that suffer from a chronic illness. Those benefits would include things like transportation to and from medical appointments and other help.

Changes to Star Ratings

CMS wants opioid and benzodiazepine misuse measures included in the star ratings for MA plans. The idea is to track use and prevent prescriptions being handed over from several providers to patients who have developed an addition – or at the very least are misusing the drug.

Generic and Brand Formulary Tiers

CMS is looking at provisions that would prevent Part D plan formulary tiers from including both generic and brand formularies. Instead, generics and brands would be kept separate.

CMS changes can be difficult to navigate and keep track of. Need help? That’s why we’re here. The team at Tier 1 Pharmacy Consulting are pharmacy benefit plan experts, providing support and consultation for all types of CMS changes. Remember, plans that fail to abide will be subject to a CMS audit.  Agency officials are watching health plans very closely this year.

Tier 1 can review changes to ensure accuracy and compliance. In the event of an audit, we will interpret data to identify potential issues, craft responses and create corrective action plans.

About Tier 1 

Tier 1 Pharmacy Consulting is a Denver, Colorado-based pharmacy benefit consulting firm offering customized services to healthcare plans that offer prescription drug benefits. Whether your health plan is big or small, Tier 1 offers strategic, cost-saving solutions that boost the plan’s overall value and help its members by providing high quality care.

Tier 1’s founder is a clinical pharmacist with more than a decade of experience in pharmacy benefit management. We are passionate about collaborating and developing effective strategies to improve health plan outcomes.

Tier 1 offers health plans a new perspective on how to manage their pharmacy benefit. Our team is made up of experts who strive to make effective plans even stronger and fill in any gaps due to a lack of time or resources.

Drop us a note at info@tieronepc.com. Let’s get connected.

Opioid epidemic a CMS priority in 2019

At least 130 people a day die of an opioid overdose in the U.S., according to the Centers for Disease Control and Prevention.

In 2017, fatal opioid overdoses were six times higher than they were in 1999. More than 191 million opioid prescriptions – including Oxycodone, Hydrocodone and Methadone – were dispensed to patients across the country that same year, the CDC reports.

“To reverse this epidemic, we need to improve the way we treat pain,” the agency’s website says. “We must prevent abuse, addiction and overdose before they start.”

Older Americans are not immune to the dangers of opioid misuse. Millions of men and women over the age of 65 are filling prescriptions for many different opioid medications at the same time, the Agency for Healthcare Research and Quality has found. Many of them are hospitalized to treat opioid-related complications.

The statistics are startling. It comes as no surprise, then, that the Centers for Medicare and Medicaid Services announced that it has issued major changes to its 2019 Medicare Part D Opioid Prescribing Policies. The changes target Medicare patients of all kinds who have been given opioids – first-timers, chronic users, users with the potential to mix medications and high-risk users who are prone to addiction.

As these new opioid safety alerts are implemented, ongoing communication between pharmacists, Part D plans and prescribers is crucial. Health plans with pharmacy benefits should take note of the following changes.

 Seven-day Supply Limit for New Patients

 Medicare Part D patients prescribed opioids for the first time will now be limited to a seven-day supply or less. If more is needed, the provider must request a coverage determination on behalf of the member. This new rule does not apply to patients already taking prescription opioids.

Opioid Care Coordination Alert

Whenever a Medicare patient whose cumulative morphine milligram equivalent is 90 or above gives a pharmacist a prescription for opioids, an alert will go out to the prescriber. The pharmacist may consult with the doctor about the patient’s need for a high MME. The idea is to address the potential for danger yet keep the doctor-patient relationship positively intact.

Drug Management

Under the new guidelines, part D plans will be required to contact doctors treating Medicare patients identified as high-risk for abuse to evaluate whether the medication is safe, medically necessary, and if the risk for misuse is there. The plan representative also will ask the provider if a Part D drug management tool is appropriate, such as a POS claim edit, pharmacy lock-in or prescriber limitation.

The Bottom Line

Health plans should be ready to implement the changes and contact providers as needed. We must work together to address to stop the opioid epidemic, and that includes properly caring for our Medicare recipients. Tier 1 Pharmacy Consulting can help you navigate it all.

Visit the Centers for Medicare and Medicaid Services for more information on its new opioid safety guidelines.

 About Tier 1 

Tier 1 Pharmacy Consulting is a Denver, Colorado-based pharmacy benefit consulting firm offering customized services to healthcare plans that offer prescription drug benefits. Whether your health plan is big or small, Tier 1 offers strategic, cost-saving solutions that boost the plan’s overall value and help its members by providing high quality care.

Tier 1’s founder is a clinical pharmacist with more than a decade of experience in pharmacy benefit management. We are passionate about collaborating and developing effective strategies to improve health plan outcomes.

Tier 1 offers health plans a new perspective on how to manage their pharmacy benefit. Our team is made up of experts who strive to make effective plans even stronger and fill in any gaps due to a lack of time or resources.

Drop us a note at info@tieronepc.com. Let’s get connected.