Reminder: DMA’s Prior Approval Criteria for Opioid Analgesics Begins Sunday

Effective this Sunday, Aug. 27, prior approval will be required for opioid analgesic doses for N.C. Medicaid and N.C. Health Choice (NCHC) beneficiaries which:

The prescribing provider may submit prior authorization requests to NCTracks through the NCTracks portal or by fax. New opioid analgesic prior authorization forms and revised clinical coverage criteria will be available on the NCTracks website.

Beneficiaries with diagnosis of pain secondary to cancer will continue to be exempt from prior authorization requirements.

This change also includes a new feature for prescribers to view only lock-in drugs or opioid analgesics when performing medication history searches for beneficiaries. However, the data represents only opioid claims paid by NC Medicaid and should not be used as a replacement for reviewing the NC Controlled Substance Reporting System (CSRS) as required by clinical coverage criteria and the recently passed Strengthen Opioid Misuse Prevention (STOP) Act, S.L. 2017-74.

It is important to note that the STOP Act further reduces the quantity for opioid prescriptions to 5 days for acute pain and 7 days for post-operative pain effective January 1, 2018. To comply with this legislative mandate, NC Medicaid will be proposing that our 14-day limit to be further reduced to 5 and 7 days accordingly.

It is also important to note that pharmacy providers may dispense a 72-hour emergency supply for drugs requiring prior authorization. Federal law requires that this emergency supply be available to Medicaid beneficiaries for drugs requiring prior authorization (Social Security Act, Section 1927, 42 U.S.C. 1396r-8(d)(5)(B)). Use of this emergency supply will ensure access to medically necessary medications. The system will bypass the prior authorization requirement if an emergency supply is indicated. Pharmacies will use a “3” in the Level of Service field (418-DI) to indicate that the transaction is an emergency fill.

Some background on this policy and NC’s Opioid Action Plan

On June 27, 2017 at the NC Opioid Misuse and Overdose Prevention Summit, NC Governor Roy Cooper and NC Department of Health and Human Services Secretary Mandy Cohen announced North Carolina’s Opioid Action Plan, which outlines the key actions to reduce opioid addiction and overdose death. The goal is to change the trajectory of opioid deaths and reduce opioid overdose deaths by 20 percent by 2021.

NC’s Opioid Action Plan was developed with community partners to combat the opioid crisis. It is a living document that will be updated as we make progress on the epidemic and are faced with new issues and solutions. Strategies in the plan include:

  • Coordinating the state’s infrastructure to tackle the opioid crisis.
  • Reducing the oversupply of prescription opioids.
  • Reducing the diversion of prescription drugs and the flow of illicit drugs.
  • Increasing community awareness and prevention.
  • Making naloxone widely available.
  • Expanding treatment and recovery systems of care.
  • Measuring the effectiveness of these strategies based on results.

Over the past several months, the NC Division of Medical Assistance (DMA) Pharmacy Program has worked collaboratively with our Pharmacy and Therapeutics Committee and Physicians Advisory Group to update clinical coverage criteria for the use of opioids for pain management based on the Centers for Disease Control (CDC) Guideline for Prescribing Opioids for Chronic Pain and to align clinical coverage criteria with the strategies of reducing the oversupply of prescription opioids available for diversion  and misuse.

These updates began on May 1, 2017, when the refill threshold for all opioids and benzodiazepines prescriptions was increased from 75 percent to 85 percent.

DMA also reports that as providers are becoming more aware of the opioid crisis, utilization data already reflects a reduction in the use of opioids and an increase in non-opioid and non-drug pain management.

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1 Comment

  • Kerry Allen Willis

    Perhaps its too much to ask but what was the basis for this program as there appears to be no evidence that it has worked anywhere else or reason to expect that it will work here?
    In an era of value based care and evidence based medicine, it would behove leaders to make value based decision that showed a positive impact was likely based on trials research and actionable intelligence.
    Unfortunately, The Governor and Sec Cohen have chosen to implement a program that will hassle physicians without any reasonable evidence that a prior approval program will decrease anything while dramatically increasing paperwork. Another problem solved without consulting with real Doctors who see real patients.
    Perhaps had either of them discussed the opioid problem with clinicians who have actually faced these problems in practice, they could have asked for a best practices implementation of proven measures that might have helped such as
    1. Mandatory drug screens and confirmations at least 3-4 per year and for cause for patients prescribed any controlled substance.
    2.Patient contracts that specify drug screening and pill counts on demand at any time
    3. Requiring records to establish significance of pain and duration and compliance with previous medical care before initiating new patients with narcotic prescriptions.
    Education on interpretation of drug testing and inappropriate results such as prescribed medicines not being present in samples tested are all effective in preventing drug diversion in our county.

    What we don’t need are political solutions adding additional burdens that amount to busy work that detracts from the work needed to help reduce drug diversion. Someone else said it better. If you can’t be part of the solution then don’t be part of making a bad problem worse.