Medicare Finalizes Plan to Limit Opioid Supply for Recipients

Update: The Centers for Medicare & Medicaid Services (CMS) announced Monday that the proposed changes had been finalized. New opioid prescriptions for acute pain will be limited to a seven-days’ supply. Insurance plans will be expected to implement a “safety edit” at 90 morphine milligram equivalent (MME) per day. Pharmacists who encounter patients filling prescriptions at or above this amount would then consult with the prescriber and use an override code if the prescriber confirms their intent. Insurance plans can also implement a “hard safety edit,” which can only be overridden by the insurer, at 200 MME or more.

Insurers will also be expected to implement “soft safety edits” to alert the pharmacist about duplicate opioid therapy and concurrent use of opioids and benzodiazepines, and will have the ability to limit “at-risk beneficiaries'” coverage for “frequently abused drugs” to certain prescribers and pharmacies.

CMS recommended that patients who are residents of a long-term care facility, in hospice care or receiving end-of-life care, or being treated for cancer-related pain be exempt from these guidelines. 

The Centers for Medicare & Medicaid Services (CMS) released a proposal on Thursday that suggests limiting the number of opioids Medicare recipients are allowed to receive.

The proposed changes, which would be implemented in 2019, include enacting hard “opioid safety edits” at the pharmacy — in other words, limiting how many opioids those utilizing Medicare’s prescription drug benefit (called “Part D”) can receive from their pharmacist. The plan sets the “safety level” at 90 morphine milligram equivalent (MME) with a seven-day supply allowance.

Demetrios Kouzoukas, CMS deputy administrator and director of the Center for Medicare, told MedPage Today that if the prescription exceeds the limit, that would act as a “trigger” for a conversation between the physician, patient and insurer about “appropriate opioid use and prescribing.” To get more than the proposed limit, the limit would have to be overridden by the patient’s insurance plan.

Another proposed change is enacting a “supply limit” for an initial opioid prescription for acute pain (i.e. seven days), potentially with or without a daily dose maximum.

CMS is also calling for “enhancing” their overutilization monitoring system by identifying “high-risk” beneficiaries who use drugs that, when taken with opioids, can increase the risk of overdose — such as gabapentin, pregabalin (Lyrica) and benzodiazepines — to ensure their plans provide appropriate “case management.”

“We are proposing important new actions to reduce seniors’ risk of being addicted to or overdoing it on opioids while still having access to important treatment options,” Kouzoukas said. “We believe these actions will reduce the oversupply of opioids in our communities.”

Medicare recipients include seniors over age 65, younger people with disabilities, and people with end-stage renal disease.

The proposed opioid limits are intended to help fight the opioid crisis, which claimed approximately 63,000 lives in 2016, according to data from the National Center for Health Statistics. However, synthetic opioids like fentanyl caused about a third of these deaths, heroin caused about a fourth, and prescription opioids caused 23 percent, down from 26 percent in 2009.

Studies show the majority of people prescribed opioids — between 1 and 12 percent — do not become addicted. Other research has shown that 75 percent of all opioid misuse starts with medication not prescribed to them.

The CMS is currently accepting comments on the proposal through March 5, 2018, before the final version is published on April 2. To submit comments, go to, enter the docket number “CMS-2017-0163” in the “search” field, and follow the instructions for ‘‘submitting a comment.’’

The Mighty reached out to the CMS for comment and has yet to hear back.

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