TO:     Pharmacies, Physicians, Physician Assistants, Nurse Practitioners, Oral Surgeons, Optometrists, Dentists, FQHCs, RHCs, Mental Health Service Providers and Nursing Homes

 

 

Effective May 1, 2019 the Alabama Medicaid Agency will begin implementing cumulative daily MME edits for opioid experienced recipients.

Higher doses of opioids are associated with higher risk of overdose and death - even relatively low dosages (20-50 MME per day) may increase risk.¹ Therefore, Alabama Medicaid will limit the amount of cumulative MME allowed per day on opioid claims. The edit will begin at 250 cumulative MME per day and will gradually decrease over time. The final cumulative MME target is scheduled to be 90 MME per day.  This edit is different, and in addition to, the short-acting opioid naïve edit implemented on November 1, 2018.

 

Phase-In Period:

Beginning May 1, 2019, Alabama Medicaid will begin with a “phase-in” period for 3 months. Claims that exceed the cumulative daily MME limit of 250 MME will be denied at the pharmacy Point of Sale (POS).  The dispensing pharmacist will be provided a universal prior authorization (PA) number on the rejection screen and may enter this universal PA number on the claim to allow it to be paid. Pharmacists are urged to notify the affected patient/prescriber to develop a plan to decrease the patient’s total daily MME.

 

Hard Edit Implementation:

Beginning August 1, 2019, opioid claims that exceed the cumulative MME edit of 250 MME/day will be denied.  The universal PA will no longer be valid to bypass the 250 MME edit.  Pharmacy override requests for quantities exceeding the MME limit may be submitted to Health Information Designs (HID) and will be reviewed for medical necessity. See link below for override form.

 

Edit Details:

·         The universal PA number to override the 250 MME edit will be 0009996321

·         The universal PA number will be provided on each cumulative MME rejection screen for the pharmacist   convenience

·         Additional edits such as therapeutic duplication, maximum quantity limitations, early refill, non-preferred edits will still apply

·         Claims prescribed by oncologists will bypass the edit

·         Long term care and hospice recipients are excluded

·         Children are included in the edit

·         A Recipient Information Sheet for prescribers and pharmacists to provide to recipients can be found at http://www.medicaid.alabama.gov/content/4.0_Programs/4.3_Pharmacy-DME.aspx.

 

 

 

 

Anticipated Phase Down:

The Agency anticipates gradually decreasing the daily cumulative MME limit every 4 months. The first decrease to 200 MME/day will be implemented on December 1, 2019.  Prior to each decrease, a new universal PA number will be assigned to override claims that exceed the new threshold.  Providers will be notified via an ALERT prior to each decrease.  Again, pharmacists are urged to notify the affected patient/prescriber to develop a plan to decrease the patient’s total daily MME.

 

Examples of MME calculations/day include:

·         10 tablets per day of hydrocodone/acetaminophen 5/325 = 50 MME/day

·         6 tablets per day of hydrocodone/acetaminophen 7.5/325 = 45 MME/day

·         5 tablets per day of hydrocodone/acetaminophen 10/325 = 50 MME/day

·         2 tablets per day of oxycodone 15 mg = 45 MME/day

·         3 tablets per day of oxycodone 10 mg = 45 MME/day

·         10 tablets per day of tramadol 50 mg = 50 MME/day

·         1 patch per 3 days of fentanyl 25mcg/hr = 60 MME/day

 

A link with more information regarding MME calculations is https://www.cdc.gov/drugoverdose/pdf/calculating_total_daily_dose-a.pdf.

 

IMPORTANT: Only if the override is denied, then the excess quantity above the maximum unit limit is deemed a non-covered service, and the recipient can be charged as a cash recipient for that amount in excess of the limit.  A prescriber must not write separate prescriptions, one to be paid by Medicaid and one to be paid as cash, to circumvent the override process.  FAILURE TO ABIDE BY MEDICAID POLICY MAY RESULT IN RECOUPMENTS AND/OR ADMINISTRATIVE SANCTIONS.  Source: Provider Billing Manual 27.2.3

 

¹ https://www.cdc.gov/drugoverdose/prescribing/guideline.html     

 

Override Requests:

Once the hard edit is implemented, the MME Override Request Form will be used by the prescriber when requesting an override. The form will be found at: http://medicaid.alabama.gov/content/9.0_Resources/9.4_Forms_Library/9.4.13_Pharmacy_Forms.aspx.

 

Any policy questions concerning this provider ALERT should be directed to the Pharmacy Program at (334) 242-5050.