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Opioid Prior Authorization ProcessProvider WebinarNovember 9, 2017

Agenda ObjectiveCDC recommendations for prescribing opioidsImplementation timelineHPP prior authorization criteriaOpiate Use Disorder Centers of ExcellenceResourcesQ&A

Presenters Christopher Casella, PharmD, MBADirector of Pharmacy Services, Health Partners Plans Danielle Dolores, RPhManager, Pharmacy Services, Health Partners Plans Dr. Tania Kolev, MDMedical Director, Health Partners Plans

Objective To obtain a full understanding of the HPP priorauthorization criteria for opioid medications toallow for minimal disruption to members HPP’s objective is for the member to be on theminimal dose for the shortest duration of opioidprescriptions

CDC guidelines This guideline is intended to improve communication betweenclinicians and patients about the risks and benefits of opioid therapyfor chronic pain, improve the safety and effectiveness of paintreatment, and reduce the risks associated with long-term opioidtherapy, including opioid use disorder, overdose, and death Assessing Benefits and Harms of Opioid sing Benefits Harms of Opioid Therapy-a.pdf

Implementation – Effective 9/15/17 Prior authorization requirements, members under 21 years ofage*– Prior authorization required for all opioid containing medications (formulary andnon-formulary) prescribed when the prescription exceeds a seven (7) daysupply AND will be limited to one opioid containing prescription per 365 days– PA required regardless of whether the member has taken an opioid previously.This applies to all new starts and current members. Prior authorization requirements, members 21 years of age andolder*– Prior authorization required for opioid containing medications for NEW STARTSONLY when the prescription exceeds a 14 day supply AND will be limited to oneopioid containing prescription per 365 days*Sickle Cell and Cancer Diagnosis will NOT require a Prior Authorization

Implementation dosage-based Prior authorizations will be required for all opioid prescriptions thatexceed a specific dose of milligrams of morphine equivalent (MME).This requirement will be applied as shown below:DateRequirement10/16/2017240mg MME per day11/13/2017120mg MME per day1/1/201890mg MME per day

Implementation – 1/1/18 Prior authorization will be required for all opioidcontaining medications regardless of priortherapy when the following parameters are met*:– Prescription exceeding a seven (7) day supply for members lessthan 21 years of age– Prescription exceeding a 14 day supply for members 21 yearsand older– More than one (1) opioid containing prescription in 365 days– Prescription exceeding a daily dosage of 90 MME*Sickle Cell and Cancer Diagnosis will NOT require a Prior Authorization

Prior authorization requirements Non-pharmacological treatment failureNon-opiate analgesics failureDiagnosis w/ chart notesTreatment planPDMP checkUrine drug screenTaper scheduleRisk factors addressedConcurrent BDZ useNaloxone offeredPain assessment documentationMore informationVisit hpplans.com/Providers

Approval duration Initial review may be approved up to three (3)months duration OR the duration of the taperplan submitted, both at Medical Director’sdiscretion. Continuation of therapy will be approved if allcriteria met for up to three (3) month durationOR taper plan duration if provided.

Continuation of Therapy Letter If further therapy is required, Health Partners will need the following information to reviewyour case:1) Copy of chart notes documenting the diagnosis including documentation ofsymptoms, imaging, or other testing which supports the diagnosis; 2) Medication history; 3)Documentation of failure, intolerance, or contraindication to non-pharmacologic treatmentand non-opioid analgesics; 4) Documentation of severe pain documented by a painassessment tool; 5) If diagnosis is neuropathic pain or migraine headaches, documentationshowing first line medications for neuropathic pain or migraine headaches have been tried;6) Documentation of the duration of treatment , treatment plan, and taper plan; 7)Documentation showing the patient has been counseled regarding adverse effects, and therisk of addiction, abuse, and misuse; 8) Evaluation for potential misuse and abusecompleted including family and social history; 9) Confirmation that the provider haschecked the PDMP (Pennsylvania Prescription Drug Monitoring Program); 10)Confirmation that urine drug screen is consistent with prescribed medications; 11) Ifconcurrent use of benzodiazepine and opioid, documentation of a taper plan to decreasethe dose of either benzodiazepine or opioid (taper plan can be for tapering one medicationat a time); 12) Evaluation of factors which increase the risk for opioid related harm and if aprescription for naloxone has been provided; 13) For long acting narcotic analgesics,documentation showing failure of short-acting narcotic analgesic.

Non-Pharmacologic Treatment AcupunctureAqua therapyPhysical therapyChiropracticNerve blocks

Tapering Plan Taper plan should be Individualized It depends on– Dose– Drug– Duration of treatment Conservative taper schedule is 5% to 10% decreasein the total daily dose q 4 weeks For medical contraindication or side effects consider more rapid/ aggressive taper

Monitoring Regularly Check the PDMP Test– Random periodic UDS(Eligible for reimbursement)– G0480 Drug test(s), definitive - 7 drug classes;– G0481 .8-14 drug classes,– G0482 .15-21 drug classes,– G0483 . 22 or more drug classes– If UDS is negative for the drug and you suspect diversion discontinue it immediately. We will not allow a renewal

Concurrent Benzodiazepine Use Prior Authorization will require a taper plan ofeither BDZ, Narcotic, or both if patient is onconcurrent therapy due to potential safetyissues: Side Effects Both cause sedation and respiratory depression – (the causeof overdose fatality) Both can cause addiction (Black box warning againstcombined use) Risk of Death: In 2015, 23% of people who died of an opioidoverdose also tested positive for benzodiazepines.

Opioid Conversion Opioid Rotation Consider reducing the starting dose by 3035% due to lack of cross tolerance. Dosing Know the total morphine milligram equivalent (MME)Use charts or conversion calculators

Opioid Conversion Calculators Study showed accuracy of opioid conversionimproved from 68% to 81% by using acalculator.– http://clincalc.com/opioids/– http://www.paindata.org/calculator.php– http://www.globalrph.com/narcoticonv.htm

MME ConversionsDrugMMEOxycodone 60mg/day90 MMEOxycodone 80mg/day120 MMEOxycodone 160mg/day240 MMEHydromorphone 23 mg/day90 MMEHydromorphone 30 mg/day120 MMEHydromorphone 60 mg/dayHydrocodone 30mg240 MME30 MME (1:1 Ratio)Fentanyl 25mcg/hour60 MMEFentanyl 50mcg/hour120 MMEFentanyl 100mcg/hour240 MMEMethadone 30mg90 MME

Examples of 240 MMEDrugMax per day; Max per monthPercocet 5/325mg32 per day; 960 per monthOxycodone 10mg16 per day; 480 per monthOxyContin 40mg4 per day; 120 per monthNorco 5/325mg48 per day; 1440 per monthNorco 7.5/325mg32 per day; 960 per monthMorphine IR 15mg16 per day; 480 per monthMorphine ER 20mg12 per day; 360 per monthMorphine ER 60mg4 per day; 120 per monthMethadone 10mg8 per day; 240 per monthHydromorphone 8mg7 per day; 210 per monthFentanyl 100mcg/hour1 patch every 72 hours; 10 patches a month

Examples of 120 MMEDrugMax per day; Max per monthPercocet 5/325mg16 per day; 480 per monthOxycodone 10mg8 per day; 240 per monthOxyContin 40mg2 per day; 60 per monthNorco 5/325mg24 per day; 720 per monthNorco 7.5/325mg15 per day; 450 per monthMorphine IR 15mg8 per day; 240 per monthMorphine ER 20mg6 per day; 180 per monthMorphine ER 60mg2 per day; 60 per monthMethadone 10mg4 per day; 120 per monthHydromorphone 8mg3 per day; 90 per monthFentanyl 50mcg/hour1 patch every 72 hours; 10 patches a month

Examples of 90 MMEDrugMax per day; Max per monthPercocet 5/325mg12 per day; 360 per monthOxycodone 10mg6 per day; 180 per monthOxyContin 40mg1 per day; 30 per monthNorco 5/325mg18 per day; 540 per monthNorco 7.5/325mg12 per day; 360 per monthMorphine IR 30mg3 per day; 90 per monthMorphine ER 20mg4 per day; 120 per monthMorphine ER 60mg1 per day; 30 per monthMethadone 10mg3 per day; 90 per monthHydromorphone 8mg2 per day; 60 per monthFentanyl 25mcg/hour1 patch every 72 hours; 10 patches a month

Temporary Supply Members are eligible for a temporary supply ofmedication that deny for prior authorization once peryear per medication Pharmacist receive a code that can be entered atpharmacy for a 5 or 15 day temporary supply– 5 days for new starts– 15 days for ongoing treatment If medication filled within the last 34 days This will NOT override prescriptions denying due to highMME

Opioid Rx 14 day supply YTD

Opioid Rx 14 day supply YTD

Opioid Use Disorder Center of Excellence(OUD COE) Prior Authorization is NOT required for treatmentof opioid use disorder if the Prescriber’s NPI isassociated with a Center of Excellence(COE) The following medications will apply:– Suboxone(16mg of less)– Buprenorphine Tablets(16mg or less)– Vivitrol DUR restrictions will still apply

Southeast OUD COEsPhiladelphia County Temple TWO Program/The Wedge Pathways/Project Home/PreventionPoint (The Steven Klein WellnessCenter) Penn Presbyterian MedicalCenter/Penn Medicine MothersMatter Program Public Health ManagementCorporation (PHMC) Jefferson Maternal AddictionTreatment, Education, andResearch (MATER)/NarcoticAddiction Rehabilitation Program ofThomas Jefferson University** Not directly contracted w/HPPBucks Penn Foundation, Inc.* (Sellersville) Family Service Association ofBucks County* (Langhorne)Delaware Center for Integrative Medicine(AIDS Care Group) (Chester) Crozer-Chester MedicalCenter* (Chester)Montgomery Community Health & DentalCare, Inc. (Pottstown) Resources for HumanDevelopment, Inc. (Norristown)

COE Resources PA Department of Health- Opioid Prescribing Guidelines– ines.aspx PA Opioid Centers of Excellence– centersofexcellence/index.htm PA Department of Health- Prescription Drug Monitoring Program– ngProgram/Pages/a/ClinicalResources.aspx

Final Message We don’t want to co-manage your patients You play a critical role in fighting the opioidepidemic You must prescribe in a manner consistent withstandard of care We want to partner with you to ensure yourpatients/our members are receiving medicallynecessary, safe, and effective care

Useful Resources g total daily dose-a.pdf Prescriber’s Letter dComparison-Chart-Prescriber-Letter-2012.pdf

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Questions? Q&A

Implementation - Effective 9/15/17 Prior authorization requirements, members under 21 years of age* - Prior authorization required for all opioid containing medications (formulary and non-formulary) prescribed when the prescription exceeds a seven (7) day supply AND will be limited to one opioid containing prescription per 365 days - PA required regardless of whether the member has .