Effective January 1, 2019, the following prescription coverage rules will be implemented for SecureCare HMO/SecureChoice PPO members.
Opioid Naïve 7-Day Supply Limit
- An opioid naïve safety edit will limit the member’s opioid to a 7-day supply if the member has not used an opioid in the past 108 days.
- A provider can request an override, however, the criteria for approval would need to be met.
Care Coordination 90 Morphine Milligram Equivalent (MME) Edit
- A coordination of care edit will occur when a member’s cumulative opioid MME amount reaches or exceeds 90 MME in the past 180-day period.
- The pharmacist will be required to address the edit before the prescription can be dispensed.
- Pharmacists may override edits for known exemptions, including long-term care, hospice, palliative or end-of-life care, and cancer.
- If none of the above exemptions are known, the pharmacist must contact the prescriber.
- The pharmacist will consult with the prescriber and after the prescriber confirms intent, the pharmacist will document the discussion and use an override code to allow the prescription to process.
We ask that prescribers who receive calls from dispensing pharmacists respond in a timely manner. Failure to coordinate with the pharmacist could delay the patient obtaining their prescription.
If you have any questions, you may contact Pharmacy Services at 1.800.624.6961, ext. 7914.