What is the opioid cumulative dose program?
The opioid cumulative dose program was created to reduce members’ likelihood of receiving unsafe levels of opioid medications.
Our program works by reviewing potentially unsafe levels of opioid medications. Examples of situations that can lead to unsafe levels of opioid medications are:
- Receiving multiple prescriptions that contain opioids at the same time (drug overlap), or
- Receiving opioid prescriptions written by multiple prescribers, when one prescriber is unaware you are receiving an opioid from another prescriber.
Our goal is to help protect you from receiving unsafe and potentially harmful levels of medication.
How does it work?
This program only applies if you are receiving opioid drugs from two or more providers. If this is true for you, our clinical team will review your claims for those opioid prescription drugs.
During a review, our team checks the milligram morphine-equivalent dosing (MME) of your medications. An MME is an estimate of how many milligrams (mg) of morphine a medication would contain, if the medication dose were converted to a similar dose of morphine. Finding the MME of your prescription claims helps us understand the level of potential harm of your opioid medications.
How will it affect me?
Depending on the MME level of your prescription claims, either your pharmacy or your prescribing provider will need to take action. We’ve made it simple with the table below:
If your prescription claims from multiple providers show MME levels of:
≥ 90 mg MME
Your pharmacy will be asked to verify that the dosage is correct for your medications.
≥ 100 mg MME
Your prescribing provider will need to submit a prior authorization request and receive Plan approval in order for your medication to be covered.
We’re here to make sure you have access to the medications you need—we also want you to be safe. If you have any questions about the opioid cumulative dose program, please contact Customer Care at 1-858-499-8300 or toll-free at 1-800-359-2002.
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 Sharp Health Plan at: 1-858-357-2534
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