Medicare Opioid Guidelines 2019 - New Rules Coming

By: Agnus Smith
Published: Thursday, January 03 2019
Last Updated: a year ago

Medicare Opioid Guidelines are changing, starting from January 1, 2019. Don’t worry if you are not aware of the latest Medicare Opioid Guidelines for 2019 though, because after reading this, you will be well aware of what the new year has in store.

While the whole world watched the fireworks on New Year’s Eve, there were a lot of people who were thinking of how the new year will bring changes for them. In particular, Medicare beneficiaries and pharmaceutical companies alike were waiting for the 2019 Medicare Opioid Guidelines, which are the limitations for high-dose opioid prescriptions for Medicare Part D beneficiaries. Here’s how the new rules will affect you.

New Rx Opioid Guidelines 2019

Medicare patients will have to follow the new Rx Opioid Guidelines 2019. The Centers for Medicare and Medicaid Services (CMS), will implement new rules from January 1, 2019. These rules, however, will make it difficult to get prescription drugs that are filled with high doses of opioid pain medication. These rules will affect millions of Medicare beneficiaries who rely on these prescriptions.

Even those patients who are new to opioids, often called ‘naïve’ patients, will be provided for only seven days. The reason for introducing such policies is to reduce the risk of people abusing or getting addicted to opioids. It is modeled after the 2016 CDC Opioid Guidelines. They are applicable to patients who are enrolled in Medicare Part D prescription drugs programs. It is good to know where you stand in opioid rules under Medicare.

Public Opinion About New Rules

These new Medicare Opioid Guidelines do not sit well with patients and advocates as they fear that too much power has been given to insurers and pharmacies. They think that they have been taking medications safely for years, and now they might be denied because of these new rules. Rick Martin, a retired pharmacist of Las Vegas, who is disabled due to chronic back pain, even went on to say that these rules might even be weaponized to deny patients of opioid medications.

Martin also says that he has spoken with three major chains in LA area, and none of them knew about the new CMS policies or how they will function. A pain management expert, Lynn Webster, also finds this policy cruel as he says that there are people who have been using it since years and none of them have shown signs of abuse.

CMS has a contract](https://www.affirmhealth.com/blog/medicare-announces-new-guidelines-on-high-dose-opioids) with dozens of private insurers that provide health coverage to almost 54 million Americans through Medicare, and approximately 70 million through Medicaid. As evident from the fact, there are millions of people who depend on CMS, any change in their policy has an impact on them.

Bob Twillman, Ph.D. and executive director of the Academy of Integrative Pain Management, says that this process of arranging talks between the pharmacists and the prescribers sounds like a good idea on the outside, but in practical life, it is going to be very tiresome. The conversations between both of them could be very time consuming, and consequently, the prescribers may prescribe a low enough dose, so it doesn’t come to phone calls.

Drug Management Program (DMPs)

When it comes to the rules, starting from January 1, Medicare insurers will adopt a program called Drug Management Program or (DMPs). This program is designed to flag patients who are deemed high risk, such as people who take opioid prescriptions from more than one doctor. Any opioid prescription which is at or above 90 MME (morphine milligram equivalent), will automatically trigger a safety edit, which will require the pharmacists to talk with the doctor who provided the dose and talk about whether it’s appropriate or not.

If the talks between pharmacists and the prescribing doctors go well and the former is satisfied with the explanation given by the latter, the pharmacist may override the safety edit and fill the prescription.

What is Hard Edit?

In 2016, about 1.6 million Medicare beneficiaries met/exceeded a dose of 90 MME. For those patients who are getting 200 MME or more, insurance companies can impose their own ‘hard edit’. This means that the pharmacists will need to consult the insurer before filling out prescription drugs. Insurers have the higher authority here, and they may also suggest the patients go to selected prescribers or pharmacies.

Who Makes Decisions On Prescriptions?

It all comes down to the fact that when it comes to finding out whether a prescription is appropriate or not, the power lies in the hands of the pharmacists and insurers, not the doctors. A Medicare advisory tells the patients that if they are getting opioids from more than one doctor, the plan holds the authority to talk to the patient’s doctors about it. If it is found out that the use of the patient’s opioids prescriptions isn’t safe, the plan may limit his coverage of these drugs.