Drug Management Program (DMP) and Opioids
Due to an opioid epidemic across the country, the Centers for Medicare and Medicaid (CMS) have implemented Opioid Utilization Policy programs and oversight of opioid prescriptions dispensed at retail pharmacies starting January 1, 2019. These new safety alerts apply to Blue Cross® Blue Shield® of Arizona (HMO) (BCBSAZ Advantage) members with a Medicare Part D prescription drug benefit and, by working with providers who prescribe these medications, are designed to address the issue of overutilization regarding our nation’s opioid epidemic to promote safe and responsible pain management.
Programs on Drug Safety and Managing Medications
According to the U.S. Department of Health and Human Services, “increased prescription of opioid medications led to widespread misuse of both prescription and non-prescription opioids before it became clear that these medications could indeed be highly addictive.” Pain relievers such as oxycodone, hydrocodone, codeine, morphine, and fentanyl are commonly prescribed for pain management and can be highly addictive if not taken as prescribed. Taking more than the required dose can create a dependency (the more you take, the more your body needs to address pain), taking medication not prescribed for you, or attempting to obtain prescriptions from different providers could be indications of being at risk for medication misuse.
BCBSAZ Advantage is committed to working with providers to ensure the prescribing of opioids is safe and effective for its members. We have a program that can help make sure our members safely use their prescription opioid medications, or other medications that are frequently abused. This program is called a Drug Management Program (DMP). If you use opioid medications that you get from several doctors or pharmacies, we may talk to your doctors to make sure your use is appropriate and medically necessary. Working with your doctors, if we decide you are at risk for misusing or abusing your opioid or benzodiazepine medications, we may limit how you can get those medications. The limitations may be:
- Requiring you to get all your prescriptions for opioid or benzodiazepine medications from one pharmacy
- Requiring you to get all your prescriptions for opioid or benzodiazepine medications from one doctor
- Limiting the amount of opioid or benzodiazepine medications we will cover for you.
If we decide that one or more of these limitations should apply to you, we will send you a letter in advance. The letter will have information explaining the terms of the limitations we think should apply to you. You will also have an opportunity to tell us which doctors or pharmacies you prefer to use. If you think we made a mistake or you disagree with our determination that you are at-risk for prescription drug abuse or the limitation, you and your prescriber have the right to ask us for an appeal. See Chapter 9 in the Evidence of Coverage (EOC) for information about how to ask for an appeal.
The DMP may not apply to you if you have certain medical conditions, such as cancer, or you are receiving hospice care or live in a long-term care facility.
What Are Safety Alerts?
The new CMS policy aims to balance addressing opioid overuse without a negative impact on the patient-doctor relationship, preserving access to medically necessary drug regimens, and reducing the potential for unintended consequences.
Prescribers and pharmacists will conduct additional safety review to determine if a member’s opioid use is appropriate and medically necessary.
If a prescription or claim is denied, it may require the prescriber to submit a Prior Authorization (PA).
What Can You Do?
As older adults, changes in body composition and metabolism, as well as other medications you may be taking, can affect how your body processes these strong and potentially addicting drugs. While many people can take their opioid or benzodiazepine prescriptions without becoming addicted and have been able to effectively manage their acute pain (lasting less than 90 days) or chronic pain (over 3-6 months and beyond), others may have a different outcome.
As you take opioid or benzodiazepine medication, it is important for you to communicate often with your doctor about the nature of your pain, how the medication may or may not be working for you, as well as side-effects you may be experiencing since starting the medication. If you feel you are becoming addicted to your pain medication, notify your doctor immediately.
National and State Resources
If you or a loved one are experiencing challenges with pain medications, national and state resources are available to learn more about opioids, benzodiazepines, or other potentially addicting drugs.
Mobilize AZ - Blue Cross Blue Shield of Arizona Invests $10 Million in Fight Against Opioid Misuse and Substance Abuse Disorder
Arizona Department of Health Services - Providing ‘real time’ data and statistics
National Public Radio (NPR) - Opioids can Derail the Lives of Older People, Too
Substance Abuse and Mental Health Services Administration - Why Do Adults Misuse Prescription Drugs?
The Washington Post - Unseen face of the opioid epidemic: drug abuse among the elderly grows
Last Updated: 3/6/19