PDF Version
TO: Pharmacies,
Physicians, Physician Assistants, Nurse Practitioners, Oral Surgeons,
Optometrists, Dentists, FQHCs, RHCs, Mental Health Service Providers, and
Nursing Homes
RE: Opioid
Cumulative Daily Morphine Milligram Equivalents (MME) Limit – MME Decrease
Effective November
1, 2023, the Alabama Medicaid Agency will implement hard edits on cumulative
daily MME claims exceeding 150 MME/day. A phase-in period for claims exceeding
120 MME/day, but less than 150 MME/day, will also be implemented.
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 began at 250 cumulative MME per day and is
gradually being decreased over time. The final cumulative MME target is
scheduled to be 90 MME per day.
Hard Edit Implementation (Greater than 150 MME):
Effective November 1, 2023, opioid claims that exceed a cumulative MME of 150
MME/day will be denied. The universal PA 0009996323 will no longer be
valid to bypass the 150 MME edit. Pharmacy override requests for
quantities exceeding the MME limit may be submitted to Kepro and will be
reviewed for medical necessity. See the link below for an override form.
Phase-In Period (120 MME – 150 MME):
Effective November 1,
2023, claims that exceed the cumulative daily MME limit of 120 MME/day will be
denied. 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.
Edit Details:
Anticipated Phase
Down:
The Agency plans to gradually decrease the daily cumulative MME limit to the
target of 90 MME/day. The next decrease will be a hard edit on claims exceeding
120 MME/day with a phase-in edit for claims that exceed 90 MME/day. The Agency anticipates implementation of the
next phase-in edit to occur in Spring 2024. 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
- 4 tablets per day of tramadol 50 mg= 40
MME/day*
- 1
patch per 3 days of fentanyl 25mcg/hr= 60 MME/day
A link with more
information regarding MME calculations is provided below.
Opioid National Drug Code and Oral MME
Conversion File Update | Opioids | CDC
*Please note tramadol MME conversion updated from 0.1 to 0.2 per CDC
recommendations.
A link to the U.S. Department of Health and Human Services Guide for Clinicians
on the Appropriate Dosage Reduction or Discontinuation of Long-Term Opioid
Analgesics can be found at
https://medicaid.alabama.gov/documents/4.0_Programs/4.3_Pharmacy-DME/4.3_HHS_Guidance_Dosage_Reduction_Discontinuation_Opioids_10-28-19.pdf.
IMPORTANT: Only when the override is denied will the excess quantity
above the maximum unit limit be deemed a non-covered service. Then 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
Override Requests:
Once the hard edit is implemented, the MME Cumulative Daily Override 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.
The Current Procedural Terminology (CPT) and Current Dental Terminology
(CDT) codes descriptors, and other data are copyright © 2023
American Medical Association and © 2023 American Dental Association (or such other date publication of CPT
and CDT). All rights reserved. Applicable FARS/DFARS apply.