Opioid cumulative dose program

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Sharp Health Plan is committed to preventing overuse and protecting patient safety. Effective January 1, 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 morphine-equivalent dosing (MED) of these medications to help avoid overuse.
    • An MED 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 dosing (MED):

Pharmacies will be notified to verify dosing.

For claims from two or more prescribers that meet or exceed 100mg morphine-equivalent dosing (MED):

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.

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