Medicare Part D opioid override code and pharmacy phone call

[painroddin]

Hello all,
Per the new CMS rule it states starting in 2019 for opioids it says pharmacy has to document discussion, does anyone know if this is once per year , or once every time opioid is filled?. I was thinking that I could send in patients note, however it states they are supposed to "document discussion", there is no way I will have to match up schedules to talk to every pharmacist. I put the pertinent text below and then the link. It is about halfway down the lengthy article.
Sorry if this is repeating question already answered but tried to search forum as haven't been on much lately.

"CMS recognizes that a tailored approach is needed to better address chronic opioid overuse at the POS. We expect all sponsors to implement an opioid care coordination edit at 90 morphine milligram equivalent (MME) per day. This formulary-level safety edit should trigger when a beneficiary’s cumulative MME per day across their opioid prescriptions reaches or exceeds 90 MME. In implementing this edit, sponsors should instruct the pharmacist to consult with the prescriber, document the discussion, and if the prescriber confirms intent, use an override code that specifically states that the prescriber has been consulted. Sponsors will have the flexibility to include a prescriber and/or pharmacy count in the opioid care coordination edit. Sponsors will also have the flexibility to implement hard safety edits (which can only be overridden by the sponsor) and set the threshold at 200 MME or more and may include prescriber/pharmacy counts."

---

Members don't see this ad.

 

[Aether2000]

Why would anyone need to prescribe that much narcotic?

 

[nvrsumr]

I find it ironic how many previous high prescribers who needed to be told by the DEA what was inappropriate opioid prescribing now are - holier than thou- after their forced conversion.

 

[lobelsteve]

I find it ironic how many previous high prescribers who needed to be told by the DEA what was inappropriate opioid prescribing now are - holier than thou- after their forced conversion.

Please elaborate. I know of some who are almost taunting the govt.

 

[BobBarker]

Also, reading that you need to get everyone at 85meq or below to avoid any problems. Just being at 90meq isn’t enough.

I had a local PCP that had many, many patients on high MEQ so has been a bit of a mad dash to 90meq the past few months.

 

[nvrsumr]

I strongly believe the vast majority of physicians knew deep inside that opioids are poison despite the the 2000s propaganda about -pain being the fifth vital, no ceiling, tolerance doesn’t equal addiction blah .... they acted in their best interest.

 

[Aether2000]

The lack of medical evidence for effectiveness coupled with definitive evidence of harm from high dose opioids are the most potent drivers for reduced dosages. We knew this long before the CDC guidelines were issued.

 

[painroddin]

Why would anyone need to prescribe that much narcotic?

Wasn't really trying to get into the whole ethical dilemma of opioids and appropriate dosing...I generally agree most pain patients don't need to be on them, however I do have a handful of patients on 50 mcg/hr transdermal fentanyl (which equates to about 120 MME) that have tried nearly every other conservative and nonconservative means possible, multiple surgeries, multiple scs trials etc.
I was more curious about logistics of is this phone call mandatory every prescription fill (might be tough to answer call on weekend if being filled by some mail in pharmacy for Express scripts for Tricare patients for instance.)

 

[Aether2000]

I am certain that is exactly their point- to make it extremely difficult to obtain the meds above a certain threshold point without jumping through some impossible hoops

 

[Ferrismonk]

When I read the guidelines earlier this year, I believe that there is a comment somewhere where there is discretion on the same amount MMED. So basically you talk once, but then will likely be okay if the Rx stays the same. At least between 90 and 200 MMED. I could be wrong though.

 

[emd123]

So, for people on 90 MED/day you lower them 1 mg/day, one less pill per month and everything is hunky dory.

89 MED/day, 89.5 MED/day and everybody is happy.

This is getting ridiculous, but ok.

Just ban the stuff. Make schedule II's all illegal unless in hospital, or less than 6 weeks from surgery, broken bone or terminal cancer. All the rest of this stuff is just peeing in the wind, as opiate deaths just keep rising, not from any of this, not from prescriptions, but black market fentanyl coming from China, through Mexico. But, get those 90 MED patients to 89!

 

[lobelsteve]

So, for people on 90 MED/day you lower them 1 mg/day, one less pill per month and everything is hunky dory.

89 MED/day, 89.5 MED/day and everybody is happy.

This is getting ridiculous, but ok.

Just ban the stuff. Make schedule II's all illegal unless in hospital, or less than 6 weeks from surgery, broken bone or terminal cancer. All the rest of this stuff is just peeing in the wind, as opiate deaths just keep rising, not from any of this, not from prescriptions, but black market fentanyl coming from China, through Mexico. But, get those 90 MED patients to 89!

So force everyone off meds and onto the black market. Unintended consequences of making this a non doctor issue for us, but throwing a lot of overdose deaths to the streets and ER. Unfortunately, addicts remain a percent of population, so if you kill them with your recommended policy, new ones are born and develop. The rate of addiction to opiates is about half of what it was in 1890.

 

[emd123]

So force everyone off meds and onto the black market. Unintended consequences of making this a non doctor issue for us, but throwing a lot of overdose deaths to the streets and ER. Unfortunately, addicts remain a percent of population, so if you kill them with your recommended policy, new ones are born and develop. The rate of addiction to opiates is about half of what it was in 1890.

What you describe is not some future possibility of an imagined policy, it's what we have right now. We're in a feedback loop, where the government puts pressure to reduce legal prescribing, people go to the black market fentanyl from China (which comes in easily by US mail) more people OD and die, so the government responds with a stronger crackdown on physician prescribing, not the overseas black market fentanyl supply which, which people take more of, causing more overdoses. And the cycle repeats.

Hammer US physicians, more deaths from chinese fentanyl. Hammer physicians, more. Even more deaths from chinese fentanyl. Repeat.

It's not magically in the future due to some post no one cares about by @emd123 on the internet. It is now. And it's a reality where every year, we're increasingly hammered for deaths from fentanyl coming via US mail, from China. How's this working out for anyone, except the federal government who gets an easy white coated scapegoat to repeatedly flog for a problem they're asleep at the wheel on?

 

[Aether2000]

The problem is that there is a good solution for substitution therapy that lowers death rates from opioid dependence (methadone, buprenorphine) but we do not have a solution for addiction itself. We have an enormous population chemically dependent on opioids and most of the time the opioids are not treating pain- they are maintaining dependency on opioids. It doesn't really matter what opioid whether it be oxycontin or heroin or fentanyl or methadone or buprenorphine. They all act on the same mu receptor. If we as a country want to reduce death rates, then buprenorphine should be more readily available (instead of patients having to make scores of calls to find anyone that will take their insurance) and should be 1/10 the current cost. If we as a country want to reduce the opioid use rates in the US, that is another matter- we really don't have any viable solutions for the addicted population bubble or for new addicts. Most who start taking buprenorphine are on it forever except for the periods that the prescriber decides to cut them off, then they go to the streets for other drugs until they can find someone else to prescribe buprenorphine.

 

[emd123]

The problem is that there is a good solution for substitution therapy that lowers death rates from opioid dependence (methadone, buprenorphine) but we do not have a solution for addiction itself. We have an enormous population chemically dependent on opioids- it doesn't really matter what opioid whether it be oxycontin or heroin or fentanyl or methadone or buprenorphine. They all act on the same mu receptor. If we as a country want to reduce death rates, then buprenorphine should be more readily available (instead of patients having to make scores of calls to find anyone that will take their insurance) and should be 1/10 the current cost. If we as a country want to reduce the opioid use rates in the US, that is another matter- we really don't have any viable solutions for the addicted population bubble or for new addicts. Most who start taking buprenorphine are on it forever except for the periods that the prescriber decides to cut them off, then they go to the streets for other drugs until they can find someone else to prescribe buprenorphine.

Buprenorphine: The safest opiate, and also the one the government made the hardest to prescribe.