Opioid management program for Medicaid/MassHealth ACO plans 

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Summary

Drug-drug interaction

Soft edit: drug-drug interaction between opioids and benzodiazepines

Drug-drug interaction

Soft edit: concurrent use of opioids and medication assisted treatment for addiction (MAT)

Drug-drug interaction

Soft edit: concurrent use of opioids and prenatal vitamins will trigger soft edit reject

Drug-drug interaction

Soft edit: concurrent use of opioids and antipsychotics will trigger soft reject edit

180 MME limit for Opioid regimens

Prior authorization will be required if a member’s opioid regimen exceeds 180 MME/day. Members with sickle cell disease, cancer, or a history of a diagnosis indicating palliative care treatment are exempt.

7 day supply initial fill

Treatment naïve member (no opiate claims in the last 120 days) will have a soft reject if attempting to fill > 7 day supply.  Members with sickle cell disease, cancer, or a history of a diagnosis indicating palliative care treatment are exempt.

Duplicate Long-Acting Opioids

For any combination of 2 or more long-acting opioids, if there is greater than 2 months of duplicate claims in a member’s claims history the opioid will require prior authorization

Duplicate Short-acting Opioids

For any combination of 2 or more short-acting opioids, powders, and combination products, if there is greater than 2 months of duplicate claims in a member’s claim’s history

Concurrent Therapy with Opioid Dependence Agents

Prior authorization is required if a member is stable on any buprenorphine product used for substance use disorder and is attempting to fill a long-acting opioid (for any length of time), a short-acting opioid for more than a 7 day supply, or short-acting opioid(s) for more than 7 days of therapy in the last 30 days.
“Stability” is defined as: 1. Buprenorphine/naloxone film or tablet, Zubsolv, or Bunavail: 60 days of therapy within the last 90 days 2. Probuphine (buprenorphine implant): history in the past 210 days. 3. Sublocade: ≥ 56 days of therapy in the last 84 days

Quantity Limit & Quantity limit for short acting opioids without long acting opioids

Claims for specified short-acting opioids over a dosage limit (120MME) and being used as monotherapy (no claim for a long acting opioid agent within the last 30 days) will reject at the pharmacy as prior authorization required.

Concurrent Opioid and Benzodiazepines

Hard Edit: Drug – 60 day overlap of opioid and benzo within last 90 days; one-way edit where only benzo will reject.

Therapeutic Dose

Hard Reject: Cumulative acetaminophen dose check (APAP); > 4 gram of acetaminophen containing products will trigger a hard reject edit

Therapeutic Dose

Hard Reject: Cumulative dose check of aspirin (>4GM) and ibuprofen (>3.2GM).

Concurrent Therapy

Concurrent use of opioids and MAT (medication assisted treatment for addiction); opioid post MAT (e.g. Suboxone) will trigger soft reject edit