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TO:  Pharmacies, Physicians, Physician Assistants, Nurse Practitioners, Oral Surgeons, Optometrists, Dentists, FQHCs, RHCs, Mental Health Service Providers, and Nursing Homes 

Effective December 2, 2019, the Alabama Medicaid Agency will implement hard edits on cumulative daily MME claims exceeding 200 MME/day.  A phase-in period for claims exceeding 150 MME/day, but less than 200 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 began at 250 cumulative MME per day and is gradually being decreased over time. The final cumulative MME target is scheduled to be 90 MME per day. 

Hard Edit Implementation (Greater than 200 MME):

Effective December 2, 2019, opioid claims that exceed a cumulative MME of 200 MME/day will be denied. The universal PA 0009996322 will no longer be valid to bypass the 200 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 (150 MME – 200 MME):

Effective December 2, 2019, claims that exceed the cumulative daily MME limit of 150 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 150 MME (but less than 200 MME) edit will

   be 0009996323.

·  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-preferred 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 http://www.medicaid.alabama.gov/content/4.0_Programs/4.3_Pharmacy-DME.aspx.

¹ https://www.cdc.gov/drugoverdose/prescribing/guideline.html

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 150 MME/day with a phase-in edit for claims that exceed 120 MME/day. This will be implemented on April 1, 2020. 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.

Examples of MME calculations/day include:

·  10 tablets per day of hydrocodone/acetaminophen 5/325 = 50 MME/day

·     6 tablets per day of hydrocodone/acetaminophen 7.5/325 = 45 MME/day

·     Claims prescribed by oncologists will bypass the edit.

·  2 tablets per day of oxycodone 15 mg = 45 MME/day

·  3 tablets per day of oxycodone 10 mg = 45 MME/day

·  10 tablets per day of tramadol 50 mg = 50 MME/day

·  1 patch per 3 days of fentanyl 25mcg/hr = 60 MME/day

A link with more information regarding MME calculations is

https://www.cdc.gov/drugoverdose/pdf/calculating_total_daily_dose-a.pdf.

A link to the U.S. Department of Health and Human Services Guide for Clinicians on the Appropriate Dosage Reduction or Discontinuation of Long-Term Opioid Analgesics can be found at

https://medicaid.alabama.gov/documents/4.0_Programs/4.3_Pharmacy-DME/4.3_HHS_Guidance_Dosage_Reduction_Discontinuation_Opioids_10-28-19.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. 

The Current Procedural Terminology (CPT) and Current Dental Terminology (CDT) codes descriptors, and other data are copyright © 2019 American Medical Association and © 2019 American Dental Association (or such other date publication of CPT and CDT). All rights reserved. Applicable FARS/DFARS apply.