CMS Guidelines for Opiate Prescribing for Medicare Members

Effective January 1, 2019, Medicare Part D members who are either filling an opiate prescription for the first time or who do not regularly take opiate medications will be limited to a seven day fill of their opiate medication.  A coverage determination may be submitted for greater than a seven day supply of medication.  All opiate prescriptions will still follow the MVP Heath Care® Medicare Part D Formulary; opiate medications which require prior authorization or submitted above the quantity limit will require a coverage determination and will not be eligible for the seven day fill limit.  Select patient populations (e.g. pain associated with active cancer treatment, enrolled in hospice or palliative care, or resident of a long-term care facility) are excluded from this seven day limit.  Pharmacists may contact prescribers to obtain additional clinical information.

To ensure your members have timely access to medications, please ensure that your office staff and on-call services are available to respond to calls for more information from pharmacists and MVP.