Opioid Management

Opioids are strong medications that are used to treat moderate to severe pain. Examples of opioids include oxycodone, hydrocodone, morphine, and fentanyl.

You may have heard about the increasing concern regarding the use of opioids. Opioids can be addictive. In addition, they can cause you to stop breathing especially at higher doses or if you take them with other substances which can slow your breathing. Some of these substances include alcohol, benzodiazepines such as alprazolam or lorazepam, muscle relaxants, and drugs to help you sleep. The number of people dying from opioids has increased dramatically since 1999. It is estimated that 115 people in the United States die each day from an opioid overdose. Because of this, Medicare and Banner - University Care Advantage (BUCA) want to make sure that you are safe if you must take opioids.

New Rules for Opioids 

As of January 1, 2019, Medicare has new rules that may affect you if you are taking opioid medications. 

High Doses of Opioids

  • This is not a new rule. It has been in effect since 2017 but there is a change for 2019.
  • If you are using opioids in an amount that is 90 morphine milligram equivalents (MME) or greater and the opioids are prescribed by two or more doctors, you may not be able to get your prescription at the pharmacy. Prior to 2019, this number was 120 MME.
  • You may be asking what MME means. It is a way to compare apples to apples. Different opioids have different effects at the same strength such as 10 mg.10 mg of one opioid does not give you the same effect as 10 mg of a different opioid. For example, oxycodone is 1 ½ times stronger than morphine.15 mg of morphine would give you the same effect as 10 mg of oxycodone. All dosages get standardized to what the effect would be if it was morphine. Apples to apples!
  • Your pharmacist can call your doctor to discuss your dose and can then allow the prescription to go through at the pharmacy if they feel it is safe for you.
  • If you are using opioids in an amount that is 200 MME or greater and the opioids are prescribed by two or more doctors, you will not be able to get your prescription at the pharmacy.
  • The pharmacist cannot approve this.Your doctor, you, or your appointed representative will need to submit a request for approval. This is called a coverage determination. Your doctor will need to tell us that it is necessary for your medical condition to use this high of a dose of opioids.
  • We want to make sure that you are using the lowest amount of opioids possible to prevent you from having serious side effects.

New to Opioid Use

  • If you do not have a prescription for an opioid that has been paid through the BUCA system in the past 60 days, you will be required to fill a prescription for a 7-day supply.
  • The pharmacy can fill a 7-day supply. Alternatively, your doctor, you, or your appointed representative can submit a request for approval (a coverage determination).
  • Once you fill the 7-day supply, you will be able to fill for a longer day supply.
  • This rule is in place to make sure people aren’t given more opioid than they need to treat a short-term problem.

Using More than One Long-Acting Opioid

  • If you try to fill a prescription for a long-acting opioid and you have a prescription for another long-acting opioid that is still active, you will not be able to get the prescription at the pharmacy if two or more different doctors prescribed them.
  • Examples of long-acting opioids include oxycodone ER (Oxycontin), morphine ER, and fentanyl patches.
  • The pharmacist can talk to your doctor and make the decision to allow this prescription to go through at the pharmacy.
  • If the pharmacist decides not to do this, your doctor, you or your appointed representative can submit a request for approval (a coverage determination).
  • Usually there is no reason to use more than one long-acting opioid.

Using an Opioid with a Benzodiazepine

  • If you are using an opioid and try to fill a prescription for a benzodiazepine, your prescription will not go through at the pharmacy. The same thing will occur if you are using a benzodiazepine and try to fill a prescription for an opioid.
  • The pharmacist can talk to your doctor and make the decision to allow this prescription to go through.
  • If the pharmacist decides not to do this, your doctor, you or your appointed representative can submit a request for approval (a coverage determination).
  • The combination of an opioid and a benzodiazepine is very dangerous and using these two types of drugs together should be avoided.

These Rules do not Apply to:

  • Members who have an active cancer diagnosis
  • Members in hospice
  • Members in long-term care facilities such as skilled nursing facilities

What Can You Do?

  • Use opioids only when absolutely necessary. If you do need to use them, use at the lowest dose for the shortest time possible.
  • Avoid other drugs like benzodiazepines as well as alcohol that can make the side effects from opioids worse.
  • Talk to your doctor about other things you can do to help your pain such as getting enough sleep, losing weight, or exercising. There are also other medications besides opioids that can help your pain.
  • Talk to you doctor if you have any questions or concerns.