2017-23: Opioid Prescription Policy Update

Date: 06/09/17

In response to the opioid epidemic, the Louisiana Department of Health (LDH) is implementing updated short-acting opioid quantity limits for Medicaid pharmacy claims for opioid naïve recipients. Also, opioid prescriptions for chronic and naïve recipients will be subject to 120 mg per day Morphine Equivalent Dosing (MED).

Effective July 10, 2017, LDH will implement seven-day quantity limits for short-acting (SA) opioids for opioid naïve recipients enrolled in Healthy Louisiana Managed Care Organizations (MCO) and Fee for Service (FFS).

MCOs, including Louisiana Healthcare Connections, are directed to implement the following opioid quantity limits at the Point of Sale (POS) on July 10, 2017, for opioid naïve recipients (no opioids in the most current 90-day period). Prior Authorization override provisions will be implemented to allow for medically necessary quantities above limits.

To mitigate administrative burden for prescribing providers, LDH is mandating the use of a standardized Opioid Analgesic Treatment Worksheet to request overrides and prior authorizations for medically necessary quantities of opioids in excess of the following limits. This worksheet is posted on our website at www.lahealth.cc/opioidworksheet.

In addition to the use of a standard form, LDH is also requiring MCOs to implement POS exemptions for selected medical conditions. For the conditions listed below, it will not be necessary to request a prior authorization to exceed the seven-day quantity limits. At LHCC, the PA exemption will occur through SMART PA process.

Diagnosis Code Exemptions

Diagnosis Code	Description
C00.*-C96.*	Cancer
Z51.5	Palliative Care

*Any number or letter or combination of up to four numbers and letters of an assigned ICD-10-CM diagnosis code.

Fentanyl Immediate Release

Quantity limits listed below are only payable for cancer diagnosis (C00.* - C96*)

Description	Dosage Form	Units/30 Day	Representative Brand
Fentanyl Citrate Immediate Release	Tablet Sublingual, Lozenge HD, Tab Effervescence, Film	120 Units	Abstral®, Actiq®, Fentora®, Onsolis®

 

Short Acting Opioid Quantity Limits

Short-Acting (SA) Opioid Quantity Limits (Units per 7-day supply within a 30-day period for opioid naïve patients)
Description	Dosage Form	Proposed Units/7 Days	Representative Brand
Codeine/Acetaminophen	Tablet	28	Tylenol® with Codeine
Hydrocodone/Acetaminophen	Tablet	28	Lortab®, Vicodin®
Hydrocodone/Ibuprofen	Tablet	28	Vicoprofen®
Hydromorphone HCl	Tablet	28	Dilaudid®
Meperidine	Tablet	28	Demerol®
Morphine Sulfate	Tablet	28
Oxycodone Oxycodone/Acetaminophen Oxycodone/Aspirin Oxycodone/Ibuprofen	Tablet/Capsule	28	Roxicodone® Endocet®, Percocet®, Roxicet®
Oxymorphone HCl	Tablet	28	Opana®
Tapentadol	Tablet	28	Nucynta®
Tramadol Tramadol/Acetaminophen	Tablet	28	Ultram® Ultracet®

Morphine Equivalent Dosing (MED)

For both opioid naïve and opioid tolerant patients

Morphine equivalents will be programmed with a limit of 120 mg per day effective July 10, 2017. Beginning May 1, 2017, prescribers of the claims that hit the edit shall be notified to encourage tapering and/or discontinuation or requesting a PA for MED override. MED will apply to opioid tolerant and naïve recipients. This will be an additional layer for the opioid naïve recipients in addition to the quantity limits. Recipients with a diagnosis of cancer and palliative care shall be exempt from the MED requirements through a Prior Authorization request. The Opioid Analgesic Treatment Worksheet will be modified for prescribers to request prescriptions that would exceed the 120 mg per day MED limit.

Educational Resources for Providers

Provider education on prescribing opioids is mandated through the MCO Drug Utilization Review process, or any other avenue available. View the Department of Health's list of online resources for providers.

Learn more about the opioid epidemic in Louisiana.

Please communicate any concerns with this policy to the LDH Medicaid pharmacy unit.