Effective September 1, 2020, the Vendor Drug Program will implement a uniform opioid policy across fee-for-service and managed care to encourage appropriate use and reduce opioid over prescribing.
The opioid policy does not apply to people receiving hospice care or palliative care, treatment for cancer, residents of a long-term care facility or another facility for which residents receive opioid substitution therapy for the treatment of opioid use disorder (OUD). The opioid policy also does not apply to other people the Texas Health and Human Services Commission elects to exempt based on an objective, confirmable physical pathology known to cause severe chronic pain not ameliorated by other therapies and for which opioid treatment is appropriate, for example sickle cell disease. If diagnoses are not available in the medical data, exemptions will be handled on a case-by-case basis through the prior authorization process.
Prospective Safety Edits
The Medicaid policies and processes listed below are conducted automatically during the pharmacy claims submission process.
Morphine Milligram Equivalents and Days’ Supply Limits
Morphine milligram equivalents (MME) per day is used to describe the potency of one opioid to another for comparison. The clinical decision for the MME per day recommendations varies depending on the client’s opioid use. Additionally, the Centers for Disease Control and Prevention (CDC) recommends starting opioid treatment with an immediate-release/short-acting formulation at the lowest effective dose, instead of an extended-release or long-acting formulation.
Opioid naïve is defined as people who have taken opioids for a duration less than or equal to (≤) seven days in the prior 60-day period. For people who are opioid naïve, Texas Medicaid must require a one-time authorization for:
- An opioid prescription exceeding a ten-day supply.
- A prescription for a long-acting opioid formulation.
- A claim or combination of claims in which the total daily dose of opioids exceeds 90 MME.
This is a one-time authorization to allow the claim to pay and does not apply to subsequent claims. Duration of prior authorization approval may not extend beyond the days' supply of the claim.
- Authorization will be required if the total daily dose of opioids exceeds 90 MME for clients that no longer meet the definition of opioid naïve. A tapering plan may be established and approved on a case-by-case basis. If approved, the authorization is approved for a six-month duration.
Days’ Supply Limits
Prescribing opioids for treatment of acute pain is rarely needed for more than ten days. Claims for opioid prescriptions are limited to a maximum of ten days for people who are opioid naïve. This limitation is intended to reduce the risk of addiction, as well as the diversion of unused opioids. The following limitations apply:
- Claims for opioid prescriptions are limited to a maximum of ten days for people who are opioid naïve.
- For clients who are 21 years of age and older, exempt prescriptions for opioids to treat acute pain under Texas Health & Safety Code Section 481.07636 from the three prescriptions per month limit for members in fee-for-service.
On an annual basis two retrospective reviews will be performed. One to monitor opioid prescribing and the other to monitor antipsychotic medication usage in children. The reviews will be performed to identify patterns of fraud, abuse, gross overuse, or inappropriate or medically unnecessary care. If outlier prescribing patterns are identified, a review must be conducted and, if necessary, an intervention, such as a letter or phone call to the prescriber or a peer-to-peer review.
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