The Contract Year (CY) 2019 Call Letter and Centers for Medicare & Medicaid Services (CMS) expectations for all sponsors to implement a real-time opioid care coordination safety edit at the time of dispensing as a proactive step to engage both patients and prescribers about overdose risk and prevention will require:

• Implementing a point of sale (POS) safety edit days’ supply limit of 7 days for initial fills of opioids (for opioid naïve patients).
• Implementing an opioid care coordination soft POS safety edit at 90 Morphine Milligram Equivalent (MME) per day.
• In implementing this edit, sponsors should instruct the pharmacist to consult with the prescriber, document the discussion, and if the prescriber confirms intent, use an override code that specifically states the prescriber has been consulted.
• Sponsors will have the flexibility to include a prescriber and/or pharmacy count in the opioid care coordination edit.
• Sponsors will also have the flexibility to implement hard safety edits and set the threshold at 200 MME or more and may include prescriber/pharmacy counts.

These new requirements have created an urgency for the National Council for Prescription Drug Programs (NCPDP) to evaluate guidance that could possibly require new reject codes and override codes for POS safety edits. The NCPDP Telecommunication Standard is the standard used for eligibility, claims processing, reporting, and other functions in the pharmacy services industry as named in the Health Insurance Portability and Accountability Act (HIPAA) and in electronic prescribing as named in the Medicare Modernization Act (MMA). With the expectation the opioid care coordination edit should be implemented in 2019, there is very little time for the industry to develop and implement a standardized communication process for these safety edits where there are variations in the exception criteria.

The opioid care coordination edit will allow pharmacists to play a greater role in patient care, but this will require the development of standardized electronic edits and documentation to facilitate POS rejects that currently require a coverage determination initiated by the prescriber. In addition, the intent of the POS soft safety edits to bypass the coverage determination process for clinical safety edits could create audit risks for the pharmacy without the additional POS codes to override soft edits in opioid care coordination. An added burden, given the implementation time frame, is the CMS expectation that sponsors’ network pharmacies and customer service representatives be adequately trained with regard to these new care coordination edits. NCPDP hopes to work with CMS in identifying effective, less burdensome approaches using industry adopted standards that will yield safer and appropriate opioid prescribing and ensure patient access to care and alleviate any confusion on the intent of the soft and hard POS edits proposed in the CY 2019 Call Letter.

On one hand, the national opioid crisis is urgent, and relying on technology to contain the crisis is essential, however, the NCPDP Telecommunication and SCRIPT standards do not currently support the edits and the necessary documentation that needs to be captured between the prescriber and the pharmacist. There will be a need to standardize this across the industry for opioid MME claim rejection and override codes. In the meantime, stakeholders would need to rely on manual attestation and documentation processes. Plan sponsors will have to review their current opioid policy to ensure a variety of tools are in place to address all the issues and to ensure their pharmacy benefit managers (PBMs) and call centers are ready in 2019.

Gorman Health Group can help in developing effective, proactive utilization management programs for Part D opioid utilization. Our experts are available to assist in the design of a comprehensive opioid overutilization prevention program that can address member, provider, and pharmacy care coordination policy per CMS guidance and expectations.

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