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March 7, 2022
MO HealthNet continues to respond to the Opioid Crisis afflicting Missourians. Over the last decade, MO HealthNet has continued to strengthen clinical policies for opioids; and expand coverage of non-opioid medications and services to treat chronic pain. MO HealthNet continues to believe in a holistic approach to treating and managing pain while also reducing the risk of patient harm, and continues to encourage providers to evaluate non-opioid options to treat patient pain. A summary of these policies follows, for more detailed information see: https://dss.mo.gov/mhd/cs/pharmacy/pages/clinedit.htm
- High Risk Therapies Clinical Edit
- Morphine Milligram Equivalent Accumulation Clinical Edit
- Opioid Dependence Agents PDL
- Opioid Emergency Reversal Agents PDL
- Opioids-Long-Acting PDL
- Opioids – Short-Acting Clinical Edit
- Transmucosal Immediate Release Fentanyl (TIRF) Clinical Edit
- Tramadol-Like Agents PDL
On April 7, 2022, MO HealthNet will reduce the daily limit of cumulative opioids from 150 morphine milligram equivalents (MME) to 90 morphine milligram equivalents for chronic non-malignant pain:
- Participants currently receiving opioid regimens in excess of the new limit will be grandfathered and allowed to continue at the current dose or lower to allow for tapering.
- Participants receiving opioids for pain management related to cancer and sickle cell disease continue to be exempt from the daily MME limit. In addition, those in hospice or receiving palliative care are also exempt from the daily MME limit.
MO HealthNet established the daily MME limit based on the risk of overdose at certain doses:
- 50+ MME per day: risk of overdose is 2 to 5 times the risk at 0 – 19 MME per day
- 100+ MME per day: risk of overdose is up to 9 times the risk at 0 – 19 MME per day
Complementary Health and Alternative Therapies for Chronic Pain Management:
- MO HealthNet offers coverage of chiropractic therapy, acupuncture, physical therapy, and cognitive-behavioral therapy for chronic pain with prior authorization.
Increased Coverage of Non-Opioid Medications:
- Removal of prior authorization requirements for:
- Lidocaine patches
- Diclofenac gel
- Celecoxib
Risk Reduction Strategies while Utilizing Opioids:
- Required naloxone co-dispensing for high-risk combinations with opioids
- Limit of no more than 7 days on initial prescriptions for opioids
- Prior Authorization requirement for opioid regimens over 50 morphine milligram equivalents per day
- Prior Authorization requirement and in-depth clinical review of opioid regimens over 90 MME per day
- In-depth clinical review prior to approval of any participants newly starting methadone
- Coverage of at-home drug disposal kits through “Safe At-Home” program
- Requirement for MO HealthNet providers to check the available Prescription Drug Monitoring Program (PDMP) prior to prescribing a controlled substance to a MO HealthNet participant
Continued Access to Medication Assisted Therapy:
- MO HealthNet continues to encourage the use of Medication-Assisted Therapy with no prior authorization required for preferred opioid use disorder medications.
Opioid Prior Authorization Process for Providers:
- Pharmacies or prescribers can call the Pharmacy Help Desk line at 1-800-392-8030, option #3, Monday-Friday 8am-9pm or Saturday and Sunday 8am-6pm.
- In addition to phone calls, providers may submit requests through CyberAccess or by faxing a Drug Prior Authorization form to 573-636-6470. To become a CyberAccess user, contact the Conduent help desk at 888-581-9797.
- If a patient has been established on an opioid(s) for 6 months or longer and the claim is rejecting at the pharmacy, the prescriber should call, fax, or submit a CyberAccess request. If faxing in a request, the following should be sent in:
- Opioid Prior Authorization Form: http://manuals.momed.com/forms/Opioid_Prior_Authorization_Fillable_PDF.pdf
- Last 6 months of office progress notes.
- Any additional medical records the provider feels are pertinent for the review of the request.
- For patients who do not meet MO HealthNet criteria for chronic opioid use or for patients who exceed the total MME limit, a pain management specialist may be consulted to review the request.
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