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RE: Opioid Cumulative Daily Morphine Milligram Equivalents (MME) Limit – MME Decrease

Effective July 1, 2024, the Alabama Medicaid Agency (Medicaid) will implement hard edits on cumulative daily MME claims exceeding 90 MME/day.

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, Medicaid will limit the amount of cumulative MME allowed per day on opioid claims. The edit began at 250 cumulative MME per day and has been gradually decreased over time. With this edit, the final cumulative MME target of 90 MME per day will be reached. 

Hard Edit Implementation (Greater than 90 MME):
Effective July 1, 2024, opioid claims that exceed a cumulative MME of 90 MME/day will be denied with no universal override available. The universal PA 0009996325 will no longer be valid to bypass the 90 MME edit. Pharmacy override requests for quantities exceeding the MME limit may be submitted to Kepro and will be reviewed for medical necessity. See the link below for an override form.

Edit Details:

• 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  CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022 | MMWR

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
  
  
• 5 tablets per day of hydrocodone/acetaminophen 10/325 = 50 MME/day
  
  
• 2 tablets per day of oxycodone 15 mg = 45 MME/day
  
  
• 3 tablets per day of oxycodone 10 mg = 45 MME/day
  
  
• 4 tablets per day of tramadol 50 mg= 40 MME/day*
  
  
• 1 patch per 3 days of fentanyl 25mcg/hr= 60 MME/day

Please visit the following link for more information regarding MME calculations:

https://ddph-materials.s3.amazonaws.com/HelpIsHere/Calculating-and-Understanding-Morphine-Milligram-Equivalents.pdf

*Please note tramadol MME conversion updated from 0.1 to 0.2 per CDC recommendations.

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 Cumulative Daily Override Form will be used by the prescriber when requesting an override. The form can 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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