July 31, 2020

Effective Sept. 1, 2020, the Vendor Drug Program will implement a uniform opioid policy across fee-for-service and managed care to encourage appropriate use and reduce opioid over-prescribing.

The opioid policy does not apply to people receiving hospice care or palliative care, treatment for cancer, residents of a long-term care facility or another facility for which residents receive opioid substitution therapy for the treatment of opioid use disorder (OUD), or other people Texas HHS elects to exempt based on an objective, confirmable physical pathology known to cause severe chronic pain not ameliorated by other therapies and for which opioid treatment is appropriate, for example, sickle cell disease. If diagnoses are not available in the medical data, exemptions will be handled on a case by case basis through the prior authorization process. VDP will revise these policies in the Oct. 2020 Pharmacy Provider Procedure Manual.

Prospective Safety Edits

The Medicaid policies and processes listed below are conducted automatically during the pharmacy claims submission process.

Morphine Milligram Equivalents and Days’ Supply Limits

Morphine milligram equivalents (MME) per day is used to describe the potency of one opioid to another for comparison. The clinical decision for the MME per day recommendations varies depending on the person’s prior opioid use. Additionally, the CDC recommends starting opioid treatment with an immediate-release/short-acting formulation at the lowest effective dose, instead of an extended-release/long-acting formulation.

  1. Opioid naïve is defined as people who have taken opioids for a duration less than or equal to seven days in the prior 60-day period. For people who are opioid naïve, Medicaid requires a one-time authorization for:
    1. An opioid prescription exceeding a ten-day supply
    2. A prescription for a long-acting opioid formulation
    3. A claim or combination of claims in which the total daily dose of opioids exceeds 90 MME.

This is a one-time authorization to allow the claim to pay and does not apply to subsequent claims. Duration of PA approval may not extend beyond the days' supply of the claim.

  1. For people no longer meeting the definition of opioid naïve, an authorization will be required if the total daily dose of opioids exceeds 90 MME. A tapering plan may be established and approved on a case-by-case basis. If approved, the authorization is approved for a six-month duration.

Days’ Supply Limits

Prescribing opioids for the treatment of acute pain is rarely needed for more than ten days. Claims for opioid prescriptions are limited to a maximum of ten days for people who are opioid naïve. This limitation is intended to reduce the risk of addiction, as well as the diversion of unused opioids.

  1. Claims for opioid prescriptions are limited to a maximum of ten days for opioid naïve people.
  2. For people age 21 and older, exempt prescriptions for opioids to treat acute pain under Texas Health & Safety Code Section 481.07636 from the three prescriptions per month limit for members in fee-for-service.

Drug Utilization Review Alerts

Texas Medicaid will return prospective drug utilization review (DUR) alerts for pharmacists on all claims when:

  1. opioids and benzodiazepines are used concurrently; and
  2. opioids and antipsychotics are used concurrently;

The alert informs the pharmacist of an increased risk of respiratory and CNS depression due to concurrent use.