Opioid cumulative dose program

Learn how Sharp Health Plan helps protect its patients from overuse.

opioid cumulative dose program
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Sharp Health Plan is committed to preventing overuse and protecting patient safety. In 2017, Sharp Health Plan began the opioid cumulative dose program for members using opioid drugs. The purpose of the program is to reduce the likelihood that members receive unsafe levels of opioid medications.

Unsafe opioid levels could be the result of a member receiving multiple prescriptions containing opioids at the same time (drug overlap), or due to a member receiving opioid prescriptions from multiple prescribers. Our goal is to help protect members from receiving unsafe levels of medication that could cause them harm.

Here’s how the program works:

  • The program is active at the point-of-sale, or pharmacy, when members fill their prescriptions.
  • The program reviews prescription drug claims for members who are receiving opioid drugs from two or more prescribers.
  • The program checks the milligram morphine-equivalent (MME) dosing of these medications to help avoid overuse.
    • An MME is a measure of how many milligrams of morphine the medication is estimated to contain, if the member’s medication dose was converted to a similar dose of morphine.
For claims from two or more prescribers that meet or exceed 90mg morphine-equivalent (MME) dosing: Pharmacies will be notified to verify dosing.
For claims from two or more prescribers that meet or exceed 100mg morphine-equivalent (MME) dosing: The prescribing doctor will need to submit a prior authorization request and obtain Plan approval in order for the medication to be covered.

Sharp Health Plan will apply the appropriate drug utilization review process to ensure access is maintained for needed medications.

If you have any questions about the opioid cumulative dose program, please contact Customer Care at 1-858-499-8330.

Opioid/benzodiazepine concurrent use program for Covered California members

The Sharp Health Plan claim processing system analyzes prescriptions to ensure that members are not using benzodiazepines and opioids at the same time (concurrently). If concurrent use is detected, the medication will stop processing at the point of sale and the pharmacist will be required to review the claim(s) for appropriate use. The following messages will be conveyed to the dispensing pharmacy:

  • Evaluate patient taking benzodiazepine and opioid concurrently.
  • Claim conflicts in therapy with member history.
  • The dispensing pharmacist will be given the opportunity to override the rejection.

The purpose of this safety program is to alert the pharmacist that concurrent use of benzodiazepines and opioids has been detected, which is a potential safety issue. If the pharmacist determines that the prescription claim(s) and/or concurrent use are appropriate, the pharmacy can override the reject. If the pharmacist determines that the prescription claim(s) and/or concurrent use are not appropriate, the pharmacist will not perform an override. A prior authorization will be required. Prior authorization requests can be submitted by the prescribing physician to CVS Health at the following numbers:

Commercial plansFax numberPhone number
Specialty medications866-249-6155866-814-5506
Non-specialty medications888-836-0730800-294-5979
Exchange plans
Specialty medications866-249-6155866-814-5506
Non-specialty medications855-245-2134855-582-2022

The prescribing physician should indicate on the prior authorization request form if the member meets any of the following criteria:

  • Cancer diagnosis
  • Hospice patient
  • Patient is receiving palliative care

Are you looking for our medical and pharmacy policies and procedures? They're located on our provider portal.