On October 1, 2019, the Health Care Authority (HCA) will update the clinical policy pertaining to opioid prescriptions for Apple Health (Medicaid).
Please read the following message from the HCA:
What is happening?
On October 1, 2019, the Health Care Authority (HCA) will update the clinical policy pertaining to opioid prescriptions for Apple Health (Medicaid) as part of the federal Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act. President Trump signed this bill into law in October 2018.
The policy change affects both the Apple Health contracted managed care organizations and fee-for-service programs.
HCA’s opioid policy is a prevention and patient safety tool. The policy will now include a daily dose limit of 120 morphine milligram equivalents (120 MME). In order to exceed the daily dose limit of 120 MME, an attestation documenting that the prescriber obtained a consult from a pain specialist, or why the prescriber or patient may be exempt from this limit, is required. HCA’s limits on acute prescriptions and on the transition from acute to chronic use remain; these are critical to reducing long-term opioid use and the risk of developing opioid use disorder.
Summary of policy requirements
For both acute and chronic prescribing, the policy limits doses to 120 MME per day without an approved attestation from the prescriber.
Patients who are already on daily doses greater than 200 MME for at least 42 days within the 90 days, prior to October 1, 2019:
- Will be grandfathered for one year and will not be subject to these limits or to prior authorization unless their dose increases from the current regimen.
The policy also limits the quantity of opioids that can be prescribed to opiate naïve patients for non-cancer pain. The limits for new opioid prescriptions will be:
- No more than 18 doses per prescription (approximately a 3-day supply) for patients age 20 or younger.
- No more than 42 doses per prescription (approximately a 7-day supply) for patients age 21 or older.
The pharmacy can override the day supply limits using an expedited authorization code when:
- You indicate “Exempt” in the text of the prescription.
- The patient is undergoing active cancer treatment, or when their pain is related to hospice, palliative care or end-of-life care.
At the point of transition from acute to chronic opioid treatment, defined as six weeks of therapy, a prior authorization is required.
You will be able to read the full policy on the HCA website beginning October 1, 2019.
Online resources available soon
Informational materials about the policy, including an online Q&A for prescribers, pharmacists, pharmacy billers, and clients, will be available on the HCA website early September 2019.