New opioid coverage policy changes effective April 1

Prominence Health Plan is focused on combating the growing problem of prescription opioids. With recent changes to the State’s opioid prescribing law effective in 2018, Prominence Health Plan’s clinical staff will ensure internal coverage policies are consistent with this law.

Effective April 1, 2018, Prominence Health Plan will implement several point-of-sale (POS) pharmacy edits to prevent inadvertent overuse for Commercial (Employer Group) and Medicare members:

  • A day supply limitation on first fill opioid claims to seven (7) days for all members that do not have a history with Prominence Health Plan of the medication prescribed.
  • Limitations on opioid claims in which a member’s morphine equivalent dose (MED) is:
    • Between 90-200mg daily. This claim denial may be overridden via prior authorization or a pharmacist review at the retail pharmacy.
    • Above 200mg daily. This claim denial may be overridden only via a prior authorization request.

For both Commercial (Employer Group) and Medicare Advantage members, Prominence Health Plan will send letters to prescriber(s) whose patient received at least 90mg daily MED. This letter asks the prescriber(s) to attest to the following:

  • Medical necessity and diagnosis to support the dosage of opioid medication(s)
  • Intention to coordinate with other prescribers and/or to reduce the opioid dosing over time
  • Treatment plan that establishes a bona fide provider-patient relationship

If a prescriber’s response is not obtained and member’s claim history still includes potentially inappropriate opioid utilization, Prominence Health Plan may place temporary POS edits to prevent further opioid fills, until the prescriber’s response is obtained.

Important Step

If you recently prescribed opioid medications, you may receive a letter from Prominence Health Plan requesting your assistance. Your prompt response is imperative in helping patients maintain safe and effective treatment with opioids.