TO: Pharmacies, Physicians, Physician Assistants, Nurse Practitioners, Oral Surgeons, Optometrists, Dentists, FQHCs, RHCs, Mental Health Service Providers, and Nursing Homes
Effective August 1, 2019, the Alabama Medicaid Agency will implement hard edits on cumulative daily MME claims exceeding 250 MME/day. A phase-in period for claims exceeding 200 MME/day, but less than 250 MME/day, will also be implemented.
Higher doses of opioids are associated with higher risk of overdose and death - even relatively low dosages (20-50 MME per day) may increase risk.1 Therefore, Alabama Medicaid will limit the amount of cumulative MME allowed per day on opioid claims. The edit will begin at 250 cumulative MME per day and will gradually decrease over time. The final cumulative MME target is scheduled to be 90 MME per day.
Hard Edit Implementation (Greater than 250 MME):
Effective August 1, 2019, opioid claims that exceed a cumulative MME of 250 MME/day will be denied. The universal PA 0009996321 will no longer be valid to bypass the 250 MME edit. Pharmacy override requests for quantities exceeding the MME limit may be submitted to Health Information Designs (HID) and will be reviewed for medical necessity. See the link below for an override form.
Phase-In Period (200 MME – 250 MME):
Effective August 1, 2019, claims that exceed the cumulative daily MME limit of 200 MME/day, but are less than 250 MME/day, will be denied. The dispensing pharmacist will be provided a universal prior authorization (PA) number on the rejection screen and may enter this universal PA number on the claim to allow it to be paid. Pharmacists are urged to notify the affected patient/prescriber to develop a plan to decrease the patient’s total daily MME.
Edit Details:
• The universal PA number to override the 200 MME (but less than 250 MME) edit will be 0009996322.
• The universal PA number will be provided on each cumulative MME rejection screen for the
pharmacist’s convenience.
• Additional edits, such as therapeutic duplication, maximum quantity limitations, early refill,
non-referred edits, etc., will still apply.
• Claims prescribed by oncologists will bypass the edit.
• Long term care and hospice recipients are excluded.
• Children are included in the edit.
• A Recipient Information Sheet for prescribers and pharmacists to provide to recipients can
be found at
Anticipated Phase Down: The Agency plans to gradually decrease the daily cumulative MME limit every 4 months. The next decrease will be a hard edit on claims exceeding 200 MME/day with a phase-in edit for claims that exceed 150 MME/day. This will be implemented on December 1, 2019. Prior to each decrease, a new universal PA number will be assigned to override claims that exceed the new threshold. Providers will be notified via an ALERT prior to each decrease.
Again, pharmacists are urged to notify the affected patient/prescriber to develop a plan to decrease the patient’s total daily MME.A link with more information regarding MME calculations is
https://www.cdc.gov/drugoverdose/pdf/calculating_total_daily_dose-a.pdf.
IMPORTANT: Only when the override is denied will the excess quantity above the maximum unit limit be deemed a non-covered service. Then the recipient can be charged as a cash recipient for that amount in excess of the limit. A prescriber must not write separate prescriptions, one to be paid by Medicaid and one to be paid as cash, to circumvent the override process. FAILURE TO ABIDE BY MEDICAID POLICY MAY RESULT IN RECOUPMENTS AND/OR ADMINISTRATIVE SANCTIONS. Source: Provider Billing Manual 27.2.3 Override Requests:Once the hard edit is implemented, the MME Override Request Form will be used by the prescriber when requesting an override. The form will be found at:
http://medicaid.alabama.gov/content/9.0_Resources/9.4_Forms_Library/9.4.13_Pharmacy_Forms.aspx.
Any policy questions concerning this provider ALERT should be directed to the Pharmacy Program at
(334) 242-5050.
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(CDT) codes descriptors, and other data are copyright © 2019
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