Opioid management program and pain management alternatives

Opioid management program for Commercial, MassHealth, and Exchange plans 

Opioid painkillers provide needed relief to those with acute or chronic pain. But given their potential for harm, and the very real–and pervasive–problem of misuse and abuse, ensuring appropriate use is more critical now than ever before. Our standard opioid management program is aligned with the “Guideline for Prescribing Opioids for Chronic Pain” issued by the Centers of Disease and Prevention (CDC) in March 2016 and contains the following features:

Inappropriate Drug Therapy Combinations
The pharmacy may need to contact the prescriber to resolve these issues:

  • Opioids & Medication Assisted Treatment (MAT): reject for an opioid claim secondary to a MAT drug (includes only buprenorphine-combination products)
  • Opioids & Benzodiazepine: reject for an opioid drug if the member has an existing claim for a benzodiazepine and vice versa
  • Opioids & Prenatal Vitamin: reject for an opioid drug if the member has an existing claim for a prenatal vitamin claim and vice versa

Inappropriate opioid quantities or dosing
The pharmacy may need to contact the prescriber to resolve these issues:

  • Members already on opioids: reject for a cumulative Short Acting Opioid/Long Acting Opioid dose check for >90 MME*/day
  • Members new to opioids: reject for a cumulative Short Acting Opioid/Long Acting Opioid dose check for >50 MME*/day
  • Members new to opioids: reject for Short Acting Opioid prescriptions for >7 day supply
  • Members new to opioids: reject for a Long Acting Opioid with no paid claim for a Short Acting Opioid

The following requires prior authorization from the prescriber:

  • Members already on opioids: Prior Authorization required for a cumulative Short Acting Opioid/Long Acting Opioid dose check for >180 MME*/day

Therapeutic Dose Limit
The pharmacy may need to contact the prescriber to resolve this issue:

  • Cumulative acetaminophen dose check (with opioid-containing drugs) >4 grams/day (reject)

Refill Threshold

  • This edit narrows the refill window for Schedule II-V controlled drugs to a 90% threshold at retail pharmacy and 80% at mail order.

Opioid Management Edits
The following require prior authorization from the prescriber if exceeding the limit:

  • Members new to opioids: Short Acting Opioids maximum 50 MME*/day
  • Members new to opioids: Short Acting Opioids 7 days supply limit
  • Members already on opioids: Short Acting Opioids maximum 90 MME*/day. 
  • All members: use of Short Acting Opioids required before Long Acting Opioids
  • All members: Quantity Limits on all Long Acting Opioids based on FDA maximum dosing frequency (i.e. once daily)
  • All members: Maximum 2 opioid fills within a 60-day time period

Pediatric (<19 years of age) Edits 
The following require prior authorization from the prescriber if exceeding the limit:

  • All pediatric members: PA required for all opioid containing cough and cold medications
  • Pediatric members new to opioids: 3 days supply limit

When patients fill a prescription for an opioid (a covered drug that is a narcotic substance contained in U.S. Drug Enforcement Administration Schedule II), they may choose to obtain a fill in a lesser quantity than the full amount prescribed.  If they do, they may then choose to later obtain the remainder of the prescribed fill.  They will not be responsible for any copayment amount beyond the amount that would normally apply if they obtained the entire fill at once.

Pain management alternatives to opioid products

If you are interested in pain management alternatives to opioid products for your patients, there are many non-opioid medications and treatments available. These include, but are not limited to, those listed below.

Non-opiate medication treatment options (Please note that some medications require PA or may have other utilization management restrictions):

  • NSAIDs
  • Topical Analgesic
  • Cox-II Inhibitors
  • Skeletal Muscle Relaxants
  • Anti-Depressants
  • Anti-Convulsants
  • Corticosteroids

Please refer to our formulary for further information about our prescription drug formulary and prior authorization requirements.

Non-medication treatment modalities:

  • Chiropractic care
  • Physical therapy services
  • Behavioral health providers with pain management-related specialties, such as cognitive behavioral therapy, pain management and treatment of chronic pain. 

These services may require prior authorization or may be subject to benefit limitations.

Additional medications and treatments are available which may also serve as pain management alternatives to opioid products. These include other medications, certain other types of therapies, treatment by certain types of non-behavioral health specialists, certain types of surgery, and certain types of injections.

*Morphine Milligram Equivalents are a way to compare different opioid medications based on their strength as compared to morphine