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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 April 1, 2024, the Alabama Medicaid Agency (Medicaid) will implement hard edits on cumulative daily MME claims exceeding 120 MME/day. A phase-in period for claims exceeding 90 MME/day, but less than 120 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, Medicaid will limit the amount of cumulative MME allowed per day on opioid claims. The edit began at 250 cumulative MME per day and has been gradually decreased over time. The final cumulative MME target is scheduled to be 90 MME per day. 

Hard Edit Implementation (Greater than 120 MME):
Effective April 1, 2024, opioid claims that exceed a cumulative MME of 120 MME/day will be denied. The universal PA 0009996324 will no longer be valid to bypass the 120 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 (90 MME – 120 MME):

Effective April 1, 2024, claims that exceed the cumulative daily MME limit of 90 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:

• The universal PA number to override the 90 MME (but less than 120 MME) edit will be 0009996325.
  
  
• The universal PA number will be provided on each cumulative MME rejection screen for the pharmacist’s convenience.
  
  
• Additional edits, such as therapeutic duplication, maximum quantity limitations, early refill, non-preferred edits, etc., 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.
  
  ¹  CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022 | MMWR
  

Anticipated Phase Down:
Medicaid 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 90 MME/day with no universal override available. Medicaid anticipates implementation of the next edit to occur on July 1, 2024. The Agency recommends providers refer to the most current ALERT for guidance. 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 can 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.

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