Jan. 7, 2019

The Center for Medicaid and Medicare Services (CMS) finalized the framework under which Medicare Part D plan sponsors may adopt drug management programs (DMPs) and announced new safety alerts to further help prevent and combat opioid overuse. Read below about BlueCross BlueShield of South Carolina’s DMPs to include the Lock-in Program and Point-of-Sale (POS) Safety Alert Updates that will be implemented in 2019.

Pharmacy and/or prescriber lock-ins

The 2019 Call Letter encourages Medicare health plans to implement a drug management program to include pharmacy and/or prescriber lock-ins to address utilization issues with frequently abused drugs (FAD). BlueCross will implement a lock-in program in 2019.  BlueCross will work with our pharmacy benefit manager (PBM), CVS/Caremark, to regularly review member utilization as part of our Safety and Monitoring Solution (SMS). Our SMS also includes care coordination, whereby BlueCross does outreach to prescribing physicians. If it is then determined that a Part D enrollee is at risk for misusing or abusing opioid or benzodiazepine medications, BlueCross may limit how Part D enrollees may get those medications. The limitations may be:

• Requiring members to get all their prescriptions for opioid or benzodiazepine medications from one pharmacy
• Requiring members to get all their prescriptions for opioid or benzodiazepine medications from one doctor
• Limiting the amount of opioid or benzodiazepine medications we will cover for member

If BlueCross determines one or more of these limitations should apply to one of our Part D enrollees, we will send the Part D enrollee a letter in advance. The letter will have information explaining the terms of the limitations. The Part D enrollee will also have an opportunity to tell BlueCross which doctors or pharmacies he or she prefers to use. If the Part D enrollee thinks BlueCross made a mistake or he/she disagrees with our determination that he or she is at-risk for prescription drug abuse or the limitation, the Part D enrollee and/or the prescriber has the right to appeal our decision. 

The DMP may not apply to Part D enrollees that have certain medical conditions, such as cancer, or he or she is receiving hospice care or living in a long-term care facility. 

If the Part D enrollee wants to appeal the restrictions that are in place, he or she will need to call BlueCross' Coverage Determinations & Appeals (CD&A) department at 855-204-2744.

Point-of-sale (POS) safety alert updates

CMS is requiring a change to the existing cMED (cumulative morphine equivalent dose) edit. Please note that this edit will now be referred to as the cMME edit or Care Coordination Edit. Previously, the edit would return a soft reject if the cMED dose was greater than 120 MME and the Part D enrollee had received opioid prescriptions from four or more prescribers in the previous 180 days. Effective Jan. 1, 2019, this edit will return a reject if the cMME dose is greater than 90 MME and the Part D enrollee has received opioid prescriptions from four or more prescribers in the previous 180 days. In addition, BlueCross will have a hard reject edit at a threshold of 200 MME. Below are all the Point of Sale edits that will be in place in 2019:

• Soft edit for concurrent opioid and benzodiazepine use
• Soft edit for duplicative long-acting (LA) opioid therapy
• Care coordination edit at 90 morphine milligram equivalents (MME)
• Hard edit at 200 MME or more (optional)
• Hard edit 7 day supply limit for initial opioid fills (opioid naïve)

CMS encourages education and training of all stakeholders on the new safety edits to help ensure Part D enrollees’ access to their medications in a timely manner. CMS has supplemented this document with a tip sheet for prescribers. Visit www.cms.gov for additional resources such as a beneficiary education brochure and Medicare Learning Network (MLN) Matters articles.