CMS Targets Medical Providers and “Other Interested Stakeholders” in Upcoming Part D Opioid Overutilization Policies Call

CMS, Medicare Set-Asides, Opioids on February 7, 2019
Posted by Jean S. Goldstein, JD, CMSP

Next week, CMS will be holding a telephone call to discuss and answer questions regarding CMS’ new opioid policies for Medicare drug plans.  CMS finalized new policies for the Part D plans to follow starting January 1, 2019.  Through this initiative, CMS is seeking to strengthen and broaden its partnership with providers to address the opioid crisis. The new policies include:

  • Improved safety alerts when patients fill opioid prescriptions at pharmacies; and
  • Drug management programs for patients at-risk for misuse or abuse of opioids or other drugs.

There are various learning materials available as related to the policies, which include:

CMS has indicated that the target audience for the February 14 call is physicians; physician assistants; nurses; nurse practitioners; dentists and other prescribers; case managers; and other interested stakeholders.  While, the call is mainly targeting medical providers, more than the Medicare Secondary Payer industry, there may some benefits to listening in on this call.  As an industry, we have been hopeful for quite some time that CMS would begin to implement limitations and devise a new methodology for prescription drug allocations in CMS approved Workers’ Compensation Medicare Set-Asides (WCMSAs), particularly when a beneficiary has treated with high dosage opioids.  However, to date, we have not seen any new methodologies or significant changes to the manner by which CMS allocates these medications.  In fact, the most updated reference guide has no significant changes or new guidance as related to opioids.  You may also recall the California Workers’ Compensation Institute’s 2017 study which documented some alarming results with respect to prescription allocations in approved WCMSAs.  Yet, here we are over a year later, still facing the same challenges, as CMS has clearly recognized the opioid epidemic; however, when utilizing CMS’ voluntary review program, approved WCMSAs still often contain overallocated prescription allocations comprised mainly of opioids.  We are once again hopeful that CMS will implement methodology changes into the voluntary WCMSA review program, which will limit the overallocation of opioids, particularly if the Part D plans will be instituting similar changes.  We will be sure to update our readers of any significant information relayed on the February 14 call, which may impact claims.