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 (MME) dosing 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.
Important updates for 2020
Beginning Jan. 1, 2020, we are introducing two important new safety limits on opioid prescriptions:
- 7-Day Acute Limit: A new opioid prescription for a severe and sudden condition is limited to a 7-day supply for a member with no opioid prescriptions in the past 90 days.
- Immediate-Release and Extended-Release Step Therapy Requirement: Use of an immediate-release opioid is required prior to receiving an extended-release opioid due to increased member risk. Prior authorization is needed if there is
no history of an immediate or extended-release opioid in the past 90-days.
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, please contact Customer Care at 1-858-499-8300 or toll-free at 1-800-359-2002.