Medicare Patients Face New Rx Opioid Rules in 2019

Medicare Patients Face New Rx Opioid Rules in 2019 — Pain News Network – December 31, 2018/ Pat Anson

The Centers for Medicare and Medicaid Services (CMS) will implement new safety rules on January 1 that could make it harder for over a million Medicare beneficiaries to get prescriptions filled for high doses of opioid pain medication.

Prescriptions for opioid “naïve” patients – those who are new to opioids — will also be limited to an initial 7-day supply, regardless of dose.

The new rules, which are modeled after the 2016 CDC opioid guideline, are intended to reduce the risk of opioid abuse and addiction.

Of course, they accomplish neither in real life.   

They only apply to patients enrolled in Medicare’s Advantage and Part D prescription drug programs, and exempt patients in palliative and hospice care or those being treated for “active” cancer-related pain.

That sounds so reasonable and obvious, but even cancer patients are being denied opioids (links) in the real world.

But patients and advocates fear the rules give too much power to insurers and pharmacies, and could result in widespread confusion or patients being denied medications they’ve taken safely for years.

CMS contracts with dozens of private insurers to provide health coverage to about 54 million Americans through Medicare and nearly 70 million in Medicaid.

CMS policy changes often have a sweeping impact throughout the U.S. healthcare system because so many insurers and patients are involved.

‘Safety Edit’ for High Dose Prescriptions

Starting January 1, Medicare insurers will adopt drug management programs (DMPs) designed to flag patients who are deemed high risk – such as those who take opioids with anti-anxiety benzodiazepines or get opioid prescriptions from more than one doctor.

Any opioid prescription at or above 90 MME (morphine milligram equivalent) will trigger an automatic “safety edit” requiring pharmacists to talk with the prescribing doctor about the appropriateness of the dose.

If satisfied with the explanation or if a prior authorization was already granted, the pharmacist could override the safety edit and fill the prescription

I’m horrified that my pharmacist, who has no idea what specific pain my opioids are treating, could demand and then “not be satisfied” by my doctor’s explanation for a higher dose and choose not to fill my prescription.

About 1.6 million Medicare beneficiaries met or exceeded a dose of 90 MME in 2016.

Insurance companies can impose their own “hard edit” for patients getting 200 MME or more, which will require pharmacists to contact the insurer before filling a prescription

Insurers will also be given greater authority to identify patients at high risk of addiction and can even require they use “only selected prescribers or pharmacies.”

This isn’t even medical anymore. Pain patients are being treated as though we were all addicted to our prescription medication.

They regard us as not much different than people on methadone maintenance for opioid addiction, who have to go to a clinic every single day to be observed taking their daily dose of medication. That’s probably what they’d like us to do as well.

The bottom line for patients is that pharmacists and insurers – not doctors — could be the final arbiters of whether a prescription is appropriate and should be filled.

If your Medicare drug plan decides your use of prescription opioids and benzodiazepines isn’t safe, the plan may limit your coverage of these drugs.”

This makes it sound as if “your Medicare drug plan” is an independent entity, now entitled to make decisions based on financial gain, not pain condition improvement.

“For example, under its DMP your plan may require you to get these medications only from certain doctors or pharmacies to better coordinate your health care.”

“The process they decided on — having pharmacists confer with prescribers — is really a good idea in the abstract, but in practice it’s going to be very burdensome,” says Bob Twillman, PhD, Executive Director of the Academy of Integrative Pain Management.

If a prescription is rejected by an insurer or pharmacist, patients have the option of paying for the medication in cash and/or filing an appeal.

But if you pay cash for opioids, that will register as a “red flag” and scare doctors away from prescribing you more.

“CMS officials have confirmed that Medicare prescription drug coverage involvement is limited to payment for medications. If a patient receives a denial of coverage, the patient has the right to pay out-of-pocket for that medication.

A Medicare denial only applies to financial coverage. It has no authority to deny the prescription itself,” says Andrea Anderson, Executive Director of the Alliance for the Treatment of Intractable Pain (ATIP).

ATIP is encouraging patients denied medication to contact a little-known CMS agency called the Beneficiary and Family Centered Care-Quality Improvement Program, where they can file an appeal or make a complaint.

Medicare patients can also be proactive by talking with their doctor and pharmacist about the new rules before getting a prescription filled. They can also seek a prior authorization from their insurer to avoid the delays of a safety edit at the pharmacy.

10 thoughts on “Medicare Patients Face New Rx Opioid Rules in 2019

  1. canarensis

    I know that No Pain Jane is celebrating like mad that her BELIEF that there’s no difference whatsoever between physical dependence & addiction has gained such traction. How anyone who’s ever been anywhere near an addict can believe that crap is another question, tho.

    Liked by 1 person

      1. canarensis

        Aw hell, did they actually make that official?!?! I haven’t looked into it…just got my functional (I hope) computer & wifi working.
        If they did, it makes me even more depressed at the (over)reach of the Church of Opiophobia.

        Liked by 1 person

        1. Zyp Czyk Post author

          It does exempt opioid use for chronic pain, but only in the fine print of the last 2 of the 11 criteria, and the general tone of it is that addiction and dependence and the same thing.

          The best examples to point out the error are coffee and SSRI asntidepressants, both of which cause dependence (and coffee also creates tolerance) and withdrawal symptoms.

          For anyone who drinks coffee regularly, suddenly stopping brings on withdrawal in the form of terrible headaches for over a week. Yet few are worried about their “coffee addiction” or their dependence on antidepressant medications, though the withdrawal from some of the SSRI’s is brutal too.


          1. canarensis

            I’ve pointed out the coffee/antidepressants thing too…too bad I’m usually preaching to the choir.
            I have had experience going cold turkey both on coffee & SSRIs –the first was my stupid idea, the second was forced upon me by one of the more arrogant & stupid doctors I’ve ever run across (& Baby, that is saying something!!). The coffee withdrawal gave me a vicious headache for a week. The Prozac withdrawal damn near killed me (what made it worse was, I’d been taken off Prozac too fast the first time I tried it, before they realized that you couldn’t suddenly stop the stuff. The second time was in about 2009, when physicians with a brain knew that…but he did it anyway, & despite me telling him in detail about the first nightmare).

            And my current, newish doc gets mad at me for not trusting him & insists that ‘medical PTSD’ doesn’t exist….

            Liked by 1 person

        2. Kimberly smith

          I just tried to fill my husband script at a new pharmacy he’s had this same script for over 2 years. The pharmacy said his insurance would only fill 7 days and needs a prior authorization. So I called silverscript they said because of the new Medicare opiod safety edits Medicare is the one not processing ut. I pointed out this is not a new rx… But he can pay cash and get it… The pharmacy blamed it on silverscript and silverrscript blamed it on the pharmacy… So who loses..we do by now having to pay cash. I’m outraged

          Liked by 1 person

          1. Zyp Czyk Post author

            This whole situation has become unhinged from reality. All these opioid “restrictions” are not preventing a single person overdosing on street drugs.


  2. rick johnson

    This is totally becoming a Nanny state and it hurts CHRONIC Pain sufferers also, Having a lifetime injury I used to see the DR> every 3 mo. for lab work an scripts , He would write 3 mo. of Lortab. Pharmacy held them on file, an fill them every 30 days.
    GOV> steps in. I see the Dr every 3 mo. writes a script BUT NOW only for one Month because Pharmacy cant hold a script on file anymore , So the next month I call the DR. then have to report to the clinic to Pick up my script at front desk. an go fill it same with following month.
    Needless to say being disabled, Poor, an having to drive 40 miles (one way) just to do that. Did I mention my vehicle is 31 years old.
    NOW MARCH 1st comes ,Dr. writes the script at my visit ,BUT NOW scripts cant be picked up at the office desk anymore, SOOO that means I an many others are forced to SEE the DR. EVERY MONTH. For the rest of our Lives.
    This mean not only the Hardship of choosing to walk an function by complying. or find an electric wheelchair to do chores an live., Not to mention the added cost, traveling the roads if my vehicle will start. And now Tax payers will pay for 12 DR. visits a year instead of 4 x,s
    this will send Soc.Sec. an Medicare costs HIGHER for our country, ITS a POLITICAL SHAM on BOTH SIDES
    They Should not link PRESCRIBED MEDS With Illegal ones like Heroin n cocaine
    Then call it a Friggin Crisis . People will fall threw the cracks and seek pain relief with Alcohol and or Illegal drugs like The for mentioned
    Or a rope or some other means. Excuse my sloppy typing , but this is Ridiculous. More deaths are from Alcohol related events, But No crisis there. huh?
    Illegal DRUGS come over our southern border or are shipped Fed ex. and even the USPS, But no crisis there either
    This is a burden on THOUSANDS of Good Americans an doesn’t stop Criminals Nor Addicts
    Shame on politicians for being too PC To Go after the REAL CRIMINALS

    Liked by 1 person

    1. Zyp Czyk Post author

      You speak the truth and I hear your frustration – I’m so sorry you’re being forced to suffer like this. How much worse does it have to get before the government realizes the “war on drugs” isn’t working? That they are condemning millions of people to lifelong pain?


  3. Pingback: Aftermath of the CDC Guideline | EDS and Chronic Pain News & Info

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