Starting in 2019, your Medicare Part D plan (MAPD or PDP
) will implement a drug management program (or drug utilization management) to monitor and limit at-risk Medicare beneficiaries’ access to frequently abused drugs (such as opioids and benzodiazepines).
This new policy is one of the highlights from the final 2019 Call Letter
and a 1,156 page Medicare Part D (unpublished) Final Rule
released on April 02, 2018 by the Centers for Medicare and Medicaid Services (CMS) and includes steps to fight the opioid epidemic
that been declared a Public Health Emergency
by the Secretary Health and Human Services (HHS).
According to the new policy, Medicare Part D plans will be permitted to have a “lock-in” feature “to limit an at-risk beneficiary’s access to frequently abused drugs to a selected prescriber(s) and/or pharmacy(ies).”
CMS will also limit “the availability of the special enrollment period (SEP) for dually or other low income subsidy (LIS) eligible beneficiaries who are identified as at-risk or potentially at-risk for prescription drug abuse under such drug management programs. At-risk determinations, which include prescriber and pharmacy lock-in, will be subject to the existing beneficiary appeals process.” [emphasis added]
What drugs are considered prescription opioids?
According to the National Institute on Drug Abuse:
"Prescription opioid medications include hydrocodone (e.g., Vicodin®), oxycodone (e.g., OxyContin®, Percocet®), oxymorphone (e.g., Opana®), morphine (e.g., Kadian®, Avinza®), codeine, fentanyl, and others. Hydrocodone products are the most commonly prescribed in the United States for a variety of indications, including dental- and injury-related pain. Oxycodone and oxymorphone are also prescribed for moderate to severe pain relief. Morphine is often used before and after surgical procedures to alleviate severe pain, and codeine is typically prescribed for milder pain. In addition to their pain-relieving properties, some of these drugs—codeine and diphenoxylate (Lomotil®), for example—are used to relieve coughs and severe diarrhea."
For further information about prescription opioids, please see: https://www.drugabuse.gov/ publications/ misuse-prescription-drugs/ what-classes-prescription -drugs-are-commonly-misused
For additional information on the government's response to the opioid epidemic please see:
The CMS page: "Reducing Opioid Misuse"
https://www.cms.gov/ about-cms/ story-page/ reducing-opioid-misuse.html
Improved Opioid Safety Alerts, 2019 Medicare Parts C&D Final Call Letter.
https://www.cms.gov/ Medicare/ Health-Plans/ MedicareAdvtgSpecRateStats/ Announcements-and-Documents.html