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Opioid Medication Management Program

Wellmark, in conjunction with pharmacy benefit manager CVS Caremark®, is strengthening the utilization management (UM) program to encourage clinically appropriate use for patients. This program is intended to ensure smaller quantities of opioids are dispensed for acute (short-term) pain needs, and is based on morphine milligram equivalents, or MME. This program is not designed to impact members with chronic pain or those undergoing care for serious illnesses.

 

These prescribing limitations are consistent with guidelines issued by the Centers for Disease Control and Prevention (CDC) and National Governor’s Association Opioid Briefing, and those under consideration by the Iowa legislature.

Enhanced MME-Based Utilization Management Program

Limit to 7-Day Supply Limit Quantity of OpioidsRequire Step Therapy

When appropriate, the length of the first prescription fill will be limited to seven days for new, acute opioid prescriptions for members who do not have a history of prior opioid use (based on their prescription claims).

 

A physician can submit a prior authorization (PA) request if it is important to exceed the seven-day fill limit.

The quantity of opioid products prescribed — including those that are combined with acetaminophen, ibuprofen or aspirin — will initially be limited to ensure amount does not exceed the maximum daily dose listed in labeling. Quantities are also ≤ 90 MME or less per day and contain ≤ 4 g APAP or ASA and ≤ 3200 mg ibuprofen.

 

Prescribers who believe a patient should exceed CDC guideline recommendations can submit a PA request for up to 200 MME per day. Quantities higher than that would require an appeal.

 

Note: Quantity limits will not apply to patients with cancer, a terminal condition or pain being managed through hospice or palliative care

Use of an immediate-release (IR) formulation will be required before moving to an extended-release (ER) formulation, unless the member has a previous claim for an IR or ER product, or the prescriber submits a PA request.

 

 

Beginning April 1, 2018, all customers will have their utilization management updated with the opioid medication management program.

 

Click on the policy name below for more detailed information regarding our policy.

 

Opioids ER - Step Therapy with MME Limit and Post Limit Policy
Opioids IR - Acute Pain Duration Limit with MME Limit and Post Limit Policy
Opioids IR - APAP-ASA-IBU Combo Products Acute Pain Duration Limit Policy
Opioids IR - APAP-ASA-IBU Combo Products Limit Policy


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