Provider Communicator Summer 2018
This is a newsletter article. The information may not be up-to-date. If you have questions, please contact your Provider Coordinator.

Opioid Risk Management Program

Quartz Health Solutions is committed to reducing the inappropriate use of prescription opioids. Excessive use of opioids can lead to addiction, overdose, and death.

New restrictions will be in place effective 8/1/2018 for Quartz (fully-insured) commercial members. These restrictions will limit: >

  • The number of days’ supply that can be filled for opioid naïve members (7 days or less)
  • The dose of opioids members can receive (cumulative daily dose of 120 morphine milligram equivalents (MME) will require an approved Prior Authorization (PA)*
  • The use of opioids in combination with other medications that may be inappropriate
* In order to avoid interruptions in therapy, members who are currently using opioids at a dose >120 MME can continue filling their opioids until 12/1/2018. This provides current utilizers time to obtain a prior authorization to continue therapy. Current members who are identified as needing to complete a Prior Authorization will be notified of this new requirement.

‡ Prior Authorization criteria is as follows –

ONE of the following conditions applies –
  • cancer-related pain, hospice, palliative, end-of-life, or long term care (LTC) residence.

– OR –

ALL of the following apply –

  • Prescriber statement indicating the dose being prescribed is medically necessary AND
  • The PDMP has been checked in the past month AND
  • Pain contract is in place AND
  • Prescription for naloxone (example: Narcan nasal spray) sent to the pharmacy AND
  • Urine compliance screen in previous 12 months

90750 – Zoster Vaccine for age <50 yrs (Shingrix)

Effective 3/1/18 –  Prior Authorization is required for those less than 50 years of age. Prior Authorization is NOT required for those age 50 and older.

Requirement for coverage - The clinic-injectable SHINGRIX vaccine must be administered in the Physician's office. Applies to all lines of business except Medicare Advantage (Senior Preferred)  

Note: If Zostavax is chosen as the Zoster vaccine, a prior authorization is needed for those age < 60. 

33282 – Implantation of Patient-activated cardiac event recorder

Effective 2/1/18 – Prior authorization is required. Applies to all lines of business except Senior Preferred      

Prior Authorization Lists

Medications, procedures and services are regularly added to the Prior Authorization list. Be sure to check it often.