Opioids

Preventing opioid use disorder: On November 1, 2017, a new Health Care Authority (HCA) clinical policy pertaining to opioid prescriptions took effect for Apple Health (Medicaid), both fee-for-service and managed care. Read the news release. A policy for the Uniform Medical Plan (UMP) for public employees and retirees takes effect January 2, 2018. 

Understand how HCA's Opioid Clinical Policy for Apple Health works.

Read the full policy

Why is HCA implementing this policy?

As medical and dental providers know, opioid use disorder (misuse and addiction) is a public health crisis in Washington State and across the country. In October 2016, Governor Inslee issued Executive Order 16-09, marshalling the state’s resources to combat this crisis. These efforts include preventing opioid use disorder as well as treating it.

HCA’s opioid clinical policy is a prevention and patient safety tool.

The policy aligns with recommendations of the Centers for Disease Control, the Washington State Agency Medical Directors Group, and the Bree Collaborative around safe and appropriate opioid prescribing.

The focus is on opiate-naïve patients and on the transition from acute to chronic use since these are critical to reducing long-term opiate use and the risk of developing opiate use disorder.

Do you prescribe opioid medications?

By prescribing the lowest effective dose for the shortest time needed, you can help prevent opioid use disorder. Risk of transitioning to chronic use rises dramatically with longer initial prescriptions. Every additional day of use increases the risk. For patients who require chronic use, best practices should be followed to ensure safety.

Prescription limits

The policy limits the quantity of opioids that can be prescribed to opiate naïve patients for noncancer pain. The limits for new opioid prescriptions will be:

  • No more than 18 doses (approximately a 3-day supply) for patients age 20 or younger.
  • No more than 42 doses (approximately a 7-day supply) for patients age 21 or older.

You can override these limits if you feel this is medically necessary, by typing “Exempt” in the text of the prescription.

At the point of transition from acute to chronic opioid treatment, defined as six weeks of therapy, the policy requires you attest that you are following best practices for opioid prescribing. These are listed on the HCA Chronic Opioid Attestation form and include actions such as checking the Prescription Monitoring Program, informing the patient about the risks of opioid use, and using a pain contract. Documentation of these practices should be in the chart, but you are not required to submit supporting materials.

Pharmacies should not turn away patients with prescriptions above the quantity limits. Prescriptions that reject for being over the allowed limit for acute use, can be dispensed as a partial fill up to that limit. Alternatively, pharmacies can call prescribers to see if an exemption or other override is appropriate. Pharmacies are encouraged to provide a handout to patients who have questions about the new Medicaid opioid policy.

Transition to chronic use

At the point of transition from acute to chronic opioid treatment, defined as six weeks of therapy, the policy requires you attest that you are following best practices for opioid prescribing. These are listed on the HCA Chronic Opioid Attestation form and include actions such as checking the Prescription Monitoring Program, informing the patient about the risks of opioid use, and using a pain contract. Documentation of these practices should be in the chart, but you are not required to submit supporting materials.

Some patients may be transitioning into chronic opioid use as early as November 1 and will need an attestation form to be completed by the provider and submitted to the patient’s health plan. For these situations, please contact the prescriber to inform them that this will be required for future prescriptions. You can verify existing chronic users by checking the PDMP or pharmacy claim records. If the patient is out of their medication and requires opioids that day, the pharmacy can use a one-time EA code for a known chronic opioid user to dispense a 7 day supply while the attestation form is being completed. 

Exemptions

  • Patients who are undergoing active cancer treatment or who are in hospice, palliative care, or end-of-life care are exempt from these restrictions.
  • Patients who have filled 90 days of opioids in the last 120 days will be grandfathered under the policy, and do not require attestation/prior authorization.

Long-acting opioids

Long-acting opioids are only approved when one of these situations exists:

  • The patient is grandfathered (already on chronic opioids before November 1, 2017).
  • The patient is undergoing active cancer treatment.
  • The patient is in hospice, palliative care, or end-of-life care.
  • You’ve followed the EXEMPT process.
  • You’ve obtained prior authorization following 42 days of therapy.

Resources

Other opioid activities

Washington Apple Health (Medicaid) opioid prescribing report

Based on technical specifications, you may receive an opioid prescribing report. Technical documentation will be available to help you interpret the report.

Nonfatal overdose letters

You may have received a nonfatal overdose letter if you had patients that had a nonfatal overdose with a concurrent opioid prescription.

Contact

HCA opioid policy
Email:
applehealthpharmacypolicy@hca.wa.gov