L.A. Care Network Pharmacies Implement New Safety Strategies for Opioids

December 2018

A doctor handing his patient a prescription

Starting January 1, 2019, new safety point-of-sale edits will be implemented to help decrease the risk of opioid overutilization and overdose death.

 

For All Lines of Business

L.A. Care Covered, L.A. Care Covered Direct, PASC-SEIU Homecare Workers Health Care Plan, Medi-Cal and Cal MediConnect

Brief Description of Point-of-Sale Edits

  • Soft Reject - when prescription opioids are filled at the pharmacy, the pharmacist must perform an additional safety check and sign-off when: 
→ The member has opioid prescriptions from 2 prescribers and pharmacies AND the total morphine milligram equivalents (MME) is > 90mg/day.
→ Opioids are used concurrently with benzodiazepines. 
→ Multiple long-acting opioids are used concurrently.

 

  • Hard Reject - when prescription opioids are filled at the pharmacy, the pharmacist must call Navitus to receive an approval to complete the fill when:
→ A refill for a CIII or a new prescription for a CII is requested when less than 90% of the previous fill was consumed (according to daily dose calculations). 

 

For the Cal Mediconnect Line of Business Only

Brief Description of Point-of-Sale Edit

  • Hard Reject - when prescription opioids are filled at the pharmacy, the pharmacist must call Navitus to receive an approval to complete the fill when:
→ An initial fill for an opioid is greater than a 7 day supply in opioid-naïve members

 

Exclusions

The following member populations are excluded from the Soft and Hard Edits:

  • hospice
  • cancer
  • long term care
  • palliative care
     

Proactive Steps

Take proactive steps when prescribing opioids:

  • Educate patients and staff on opioid safety measures.
  • Co-prescribe naloxone with opioids.
  • Establish realistic treatment goals with patients for pain and function.
  • Follow state and federal requirements.
  • Submit a Prior Authorization (PA) request when clinically appropriate doses exceed health plan quantity limits.
  • Communicate with dispensing pharmacists as necessary when treatments exceed point of sale safety edits.
For Medicare guidance, review the CMS Final Contract Year 2019 Call Letter.