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Senior Preferred (HMO) Opioid Drug Management Program

Beginning in 2019, to meet CMS’s requirements and to combat opioid overuse, Senior Preferred (HMO) has put several new drug management programs in place.

  • Safe dosage levels
    Opioid prescriptions will be monitored for safe dosage levels at the pharmacy. If a patient’s opioid prescriptions are above a certain limit, the prescription claim will stop for review by the pharmacist to make sure that the prescription is medically necessary and appropriate. This process may require a call to the prescriber. Senior Preferred will stop opioid prescriptions at the pharmacy if –

    • The cumulative daily Morphine Milligram Equivalent (MME) dose is ≥ 90 MME and
    • Two or more prescribers are involved. If the prescription is verified as medically necessary, the pharmacist will then be able to enter an override on the claim at the pharmacy. A formal prior authorization request should not be needed.
  • Opioid prescriptions taken with benzodiazepine prescriptions
    The opioid prescription claim will stop at the pharmacy for review by the pharmacist to make sure that the prescriptions are medically necessary and appropriate.
  • Seven-day supply for a new prescription
    Members who have not had a recent prescription for opioids will be limited to a seven-day supply for their first opioid prescription.
  • Prescriptions for long-acting opioids
    Prescriptions for more than one long-acting opioid that are taken at the same time will stop at the pharmacy for review. The pharmacist will verify that by the prescriptions are medically necessary and appropriate.

Patients may be exempt from these drug management programs if they have cancer and / or are in a hospice or long-term care facility.

For additional information, see MLN Matters SE18016

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